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SAUNDERS' 


MEDICAL  HAND-ATLASES. 

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ATLAS  AND  EPITOME 


DISEASES  CAUSED  BY  ACCIDENTS 


DR.  ED.  GOLEBIEWSKI 


OF    BERLIN 


AUTHORIZED  TRANSLATION   FROM  THE  GERMAN,  WITH 
EDITORIAL  NOTES  AND  ADDITIONS 


PEARCE    BAILEY,   M.D. 

CONSULTING  NEUROLOGIST  TO  ST.  LUKE's    HOSPITAL  AND   THE   ORTHOPEDIC  HOSPITAL, 

NEW  YORK,  AND  TO  ST.  JOHN's  HOSPITAL,  YONKERS  ;    ASSISTANT  IN  NEUROLOGY, 

COLUMBIA   university;     AUTHOR  of   "  ACCIDENT   AND   INJURY  :     THEIR 

RELATIONS   TO    DISEASES   OF  THE    NERVOUS   SYSTEM  " 


40  COLORED  PLATES,  AND  143  ILLUSTRATIONS  IN  BLACK 


PHILADELPHIA 

W.  B.  SAUNDERS  &  COMPANY 
1900 


Copyright,  1900, 
By  W.  B.  SAUNDERS  &  COMPANY. 


PRESS  OF 
W.    B.    SAUNDERS    A.    COMPANY. 


PREFACE. 


The  intention  in  pnblishingthis  "Atlas  and  Epitome"  is 
to  present  a  systematic  description  of  the  sequels  of  injuries 
caused  by  accidents.  The  book  is  expected  to  be  of  in- 
terest not  only  to  medical  practitioners,  but  also  to  stu- 
dents, who,  it  is  hoped,  will  find  it  a  concise  and  useful 
manual  supplying  a  deficiency  in  medical  literature.  By 
reason  of  its  illustrations  and  the  large  number  of  descrip- 
tive cases,  the  work  should  also  prove  useful  to  laymen 
whose  interests  are  connected  with  accident-insurance. 

The  book  is  divided  into  two  parts,  one  treating  of  in- 
juries in  general,  the  other  of  injuries  aifecting  special 
structures  and  regions  of  the  body. 

The  symptomatology  of  the  sequels  of  the  various  forms 
of  injury,  as  given  in  the  text,  date  either  from  the  time 
when  the  surgeon  is  usually  succeeded  by  his  medical  col- 
league, or  from  the  termination  of  both  medical  and  surgi- 
cal treatment,  when  tlie  patient  is  ready  to  resume  work 
or  to  receive  a  certificate  of  disability,  as  the  case  may  be. 
The  illustrations  conform  to  the  same  rule. 

The  symptomatology,  therefore,  of  a  large  number  of 
the  sequels  corresponds  to  the  fourteenth  week  after  in- 
jury ;  while  in  some  other  cases — the  traumatic  nervous 
diseases,  for  instance — it  applies  to  a  much  later  period. 

The   date   chosen   for  the  illustrations  is  also  variable, 

11 


12  PREFACE. 

according  to  the  time  required  for  recovery  or  the  ability 
to  resume  work. 

The  colored  j)lates  are  copied  from  original  water- 
colors,  done  for  the  most  part  from  life,  by  Mr.  Fink, 
whose  work  gives  evidence  of  keen  perception  t)f  medical 
requirements  as  well  as  of  artistic  merit.  The  illustrations 
in  black  and  the  pen-and-ink  drawings  also  testify  to  his 
ability. 

The  other  illustrations  and  skiagraphs  are  from  ])h()to- 
graphs,  drawings,  sole-imprints,  etc.,  made  in  my  hos})ital. 

The  chapters  on  anatomy  are  based  on  original  studies 
on  the  cadaver  as  well  as  on  living  subjects. 

The  works  of  other  and  better  known  writers  have 
been  freely  consulted,  with  due  acknowledgment  in  the 
text,  whenever  appropriate.  I  refer,  among  others,  to  the 
works  of  Thiem,  Wagner  and  Stolper,  F.  Konig,  Hel- 
ferich,  Hoifa,  Kaufman  n,  Rauber,  Poirier,  Bardeleben, 
Ferd.  Baelir,  and  F.  Riedinger.  The  text  in  general  is 
based  on  an  experience  with  accident-cases  extending  over 
thirteen  years,  and  embracing  a  total  of  5245  cases,  a  con- 
siderable number  of  which  have  remained  under  observa- 
tion since  the  first  few  years  following  the  passage  of  the 
Accident-insurance  Law.  Each  class  of  injuries  is  })ref- 
accd  by  a  reference  to  the  number  of  cases  personally 
observed. 

The  "Atlas  and  Ej)itome  "  does  not  claim  to  cover  the 
subject  completely,  certain  special  branches,  such  as  in- 
juries of  the  eyes,  ears,  and  female  generative  organs,  not 
being  even  touched  U])on.  The  style  is  condensed,  as  is  to 
be  expected  in  a  work  of  this  character,  but  much  that  is 
omitted  in  the  text  is  supplied  in  the  descriptive  cases. 


PREFACE.  13 

The  illustrations  of  certain  chapters  have  had  to  be  cur- 
tailed, owing-  to  technical  imperfections  in  the  skiagraphs 
which  made  them  useless  for  purposes  of  reproduction. 
This  applies  especially  to  skiagraphs  of  the  pelvis,  hip- 
joint,  and  spine. 

I  desire  to  express  my  appreciation  of  the  willingness 
of  the  publisher  to  assume  the  very  considerable  expense 
incidental  to  the  preparaticMi  of  this  book. 

Its  readers  will  recognize  that  the  work  is  in  many  re- 
spects imperfect,  entering  as  it  does  upon  a  field  in  which 
we  still  have  much  to  learn  from  experience.  I  shall  be 
sincerelv  grateful  for  any  suggestion  or  advice  tending  to 
remedy  its  faults. 

The  Authoe. 


CONTENTS, 


PAGE 

IXTRODUCTION   TO  THE   AMERICAN    EDITION 23 


I.  GENERAL  CONSIDERATIONS. 

Causes  of  Accidexts 33 

Accidents 35 

Statistics  of  Accidents 35 

Mortality  Table     37 

General  Remarks  on  Injuries  and  Traumatic  Disorders  37 

General  Remarks  on  Injuries. 

Injuries  and  Traumatic  Diseases  of  the  8kin 38 

Injuries  and  Traumatic  Diseases  of  the  Nails      ....  46 
Injuries  and  Traumatic  Diseases  of  Muscles  and  Ten- 
dons                  .47 

Injuries  and  Traumatic  Diseases  of  Tendons  and  Ten- 
don-sheaths       52 

Injuries  and  Traumatic  Diseases  of  Burs.t?      53 

Injuries  and  Traumatic  Diseases  of  Fasci.e 54 

Injuries    and    Traumatic    Diseases    of    Ligaments    and 

Joint-capsules 55 

Injuries  and  Traumatic  Diseases  of  the   Blood-vessels  55 

Injuries  and  Traumatic  Diseases  of  the  Nerves       ...  57 

Injuries  and  Traumatic  Diseases  of  the  Bones      ....  61 

Injuries  and  Traumatic  Diseases  of  the  Joints     ....  70 
The  Influence  of  Traumatism  on   the   Development  of 

Tumors 80 

Intoxications     81 

Infectious  Diseases 83 

15 


16  CONTENTS. 

II.  SPECIAL  STRUCTURES. 

PAGE 

Injuries  and  Traumatic  Diseases  of  the  Head 88 

Contusions  of  the  Head 91 

Fractures  of  the  Skull      iC? 

Traumatic  Diseases  of  the  Brain  and  Its  Meninges 103 

Functional  Neuroses 107 

Injuries  of  the  Face       115 

Injuries  and  Traumatic  Diseases  of  the  Neck 121 

The  Trunk 121 

The  Vertebral  Column      121 

General  Symptoms  of  Traumatic  Diseases  of  tlie  Spinal  Cord  128 
Injuries  Involving  the  Spinal  Cord;  Concussion  of  the  Cord    .  132 

Injuries  Involving  the  Spinal  Meninges       133 

Traumatic  Hemorrhages  in  the  Spinal  Cord 135 

Symptoms  of  Injuries  Involving  the  Spinal  Cord 138 

Traumatic  Diseases  of   the   Spinal  Column,   Meninges,   and 

Cord      170 

Contusion  and  Crushing  of  the  Back  182 

Injuries  and  Traumatic  ^iseases  of  the  Chest      ....  186 

Contusions  of  the  Thorax 187 

Commotio  Pectoris 190 

Wounds  and  Cicatrices  of  the  Chest      191 

Subcutaneous  Rupture  of  Muscles  . 192 

Fracture  of  the  Sternum      193 

"  "      Ribs      194 

"  "      Costal  Cartilages 201 

Dislocation  of  the  Ribs 201 

Se((uels  of  Fractvn'e  of  the  Ribs 202 

Injuries  and  Traumatic  Diseases  of  the  Heart  and  Pericar- 
dium      208 

Injuries  and  Traumatic  Diseases  of  the  Abdomen   .   .   .  212 

The  Abdominal  Wall 212 

The  Stomach       213 

The  Intestine  and  Peritoneum 216 

The  Liver 219 

The  Spleen      220 

The  Pancreas      220 

Tlie  Kidney 221 

The  Bladder,  Ureters,  Testicles,  and  Penis 224 

Hernia 227 


CONTENTS.  17 

PAGE 

Injurip:s  and    Traumatic    Diseases    of    the    Upper  Ex- 
tremity      23G 

The  Slioulder      236 

The  Arm      264 

The  Elbow-joint    . 2S0 

The  Foreanu      288 

The  Wrist 304 

The  Hand  and  Fingers 317 

Injuries  and   Traumatic    Diseases   of   the    Lower   Ex- 
tremity      353 

The  Telvis       356 

The  Hip-joint 363 

The  Thigh 366 

The  Knee 392 

The  Leg 417 

The  Foot  and  Ankle 448 

Index     537 


COLORED   PLATES. 


Plate    1. — Diajjram  of  the   Lateral  Convexity  of  the  Skull  and  the 

Brain  Centers  Ac^-ording  to  Bardeleben. 
Plate    2. — Fig.     1. — Circular  Depression  and  Scar  in  the  Middle  of  the 
Forehead  after  a  Compound  Fracture. 
Fig.    2. — Deep  Scar  and  Opening  in  the  Left  Frontal  Bone 
after  a  Coniniinuted  Fracture. 
Plate    3. — Fig.     1. — Represents  a   Hod-c<u'rier,  Thirty-nine   years  of 
Age,  after  Reco\'ery  from  a  Compound  Fracture 
of  the  Skull  (Frontal  Bone),  Fracture  of  the 
Nasal  Bone,  of  the  Right  Malar  Bone,  and  of 
the  Right  Side  of  the  Inferior  Maxilla,  with 
Concussion  of  the  Brain. 
Fig.    2. — Case  of  Left  Facial   Paralysis,  with  Atrophy  of 
the  Left  Side  of  the  Face,  after  a  Fracture  of 
the  Base  of  the  Skull. 
Plate    4. — Fig.     1. — Ptosis  and   Internal   Strabismus  after  a  Severe 
Comminuted  Fracture  of   the   Skull  (Feeble- 
mindedness and  Crinunal  Tendencies). 
Fig.  In. — ShoAving  Cicatrix  of  Figure  1. 
Fig.    2. — Cicatrix,  with  Long  and  Ifcither  Deep  Depression 
in  the  Bone,  Located  on  the  Left  Side  of  the 
Skull,  and  Commencing  at  About  the  Upper 
Angle  of  the  Occipital  IJone. 
Plate    5. — Fig.     1. — Adherent  Scar  over  the  Left  ]Malar  Bone,  Follow- 
ing Contusion  and  a  Probable  Fracture.    Infra- 
orbital Neuritis  of  Left  Side. 
Fig.    2. — Nan'owing  of  the  Entrance  of  the  Right  Nostril 
in  Consequence  of  a  Conii)ound  Fracture  of  the 
Nasal  Bones.     (See  also  illu.stration.  Fig.  4,  p. 
117.) 
Plate    6. — Paralysis  of  the  Sympathetic  Ner\'e  on  the  Left  Side,  with 

Atrophy  of  the  Corresponding  Side  of  the  Face. 
Plate    7. — Contracture  of  the  Left  Trapezius  Following  Severe  Contu- 
sions of  the  Left  Side  of  tlie  Head  and  Body.    ( Hysteria. ) 
Plate    8. — Recovery  from  a  Rotatory  Fracture  of  the  Third  Cervical 
Vertebra  and  Its  Spinous  Process, 

19 


20  COLORED   PLATES. 

I'late    9. — Case  of  Fracture  of  Luiiil)ar  Veitebnc  Following  a  Slight 
Injury.     Tuberculosis  of  the  Lunilmr  Vertebra?.     Subse- 
quent Development  of  an  Angular  Curvature. 
Plate  10. — Fig.     1. — Compound  Fracture  of  the  Sternum  and  the  First 
Rib  on  the  Left  Side.     Scar  Adherent. 
Fig.    2. — Ununited  Indirect  Fracture  of  the  Seventh  Kib 
on   the   Left   Side,  Showing  a  Small   Round 
Tumor. 
Plate  11. — Exostosis  of  the  Seventh  Rib  on  the  Right  Side  Near  the 
Mamillary  Line.     The  Case  Was  Complicated  by  Frac- 
ture of  the  Ninth  or  Tenth  Vertebra  and  of  Several  Ribs 
Near  the  Vertebral  Colunni. 
Plate  12.— Contusion  of  the  Left  Side  of  the  Thorax  Following  a  Fall. 

(Thickened  pleura,  tuberculosis. ) 
Plate  13. — Acquired  Ventral  Hernia  Intensified  by  Traumatism. 
Plate  14. — Scar  Resulting  from  Operation  for  Right  Inguinal  Hernia. 
Plate  15. — Large  Ventral  Hernia  of  the  Right  Side  Due  to  Stretching 

of  a  Deeply  Attached,  Funnel-shaped  Cicatrix. 
Plate  If). — Consolidated   Fracture   of   the   Left   Clavicle,    Showing  a 

Slight  but  Characteristic  Deformity. 
Plate  17. — Consolidated  Fracture  of  the  Left  Clavicle  at  its  Sternal 

Extremity,  Showing  a  Well-marked  Deformity. 
Plate  18. — Extreme  Degree  of  (Progressive)  Muscular  Atrophy  of  the 
Right  Shoulder,  Arm,  and  Chest  and  Scoliosis  Following 
Dislocation  of  the  Right  Arm  at  the  Shoulder.     (Par- 
alj'sis  of  the  brachial  plexus. ) 
Plate  19. — Subcutaneous   Rupture  of   the   Long   Head  of  the  Right 

Biceps. 
Plate  20. — Extensi\e  Scar  of  the  Right  Forearm  Following  an  Acci- 
dent in  Which  tlie  Forearm  Was  Crushed  and  Muscles 
and  Tendons.Were  Ruptured.      (The  hand  can  be  only 
partly  closed. ) 
Plate  21. — Scar-keloid  on  the  Dorsal  Surface  uf  the  Right  Hand.    (See 

also  Figs.  40  and  41.) 
Plate  22. — Trophoneurosis  of  the  Hand  and  Fingers  Following  Sever- 
ance of  the  Median  and  Ulnar  Nerves. 
Plate  23. — Retracted  Scar  over  the  Back  of  the  Right  Wrist  Prevent- 
ing Flexion. 
Plate  24. — Contracture  of  the  Fingers  Rendering  the  Hand   Useless; 
Extensive  Operation-scars.      (Case  of  cellulitis  following 
a  slight  lacerated  wound  of  the  tlnmib. ) 
Plate  25. — Fig.     1. — Atropliy  of  the  liight  Arm  and  Forearm  Follow- 
ing Compound  Dislocation  of  the  Index-finger. 
(The  hand  is  shown  tightly  closed,  with  the 
extensor  surface  forward. ) 
Fig.    2.— The  Normal  Arm. 
Plate  20. — Fig.     1. — Atrophy  of   Forearm  and    Hand   (same   case   as 
Plate  25),  Showing  tlie  Flexor  Surface.      (The 
index-finger  is  subluxated   and  can   Ije  only 
partly  flexed.) 


COLORED  PLATES.  21 

Plate  27. — Atroj)liy  of  the  Hand  after  a  Fracture  of  tlie  Radius  (Com- 
pression of  Median  Nerve  by  Scaphoid  Bone). 
Fig.     1. — Xornial  Hand. 
Fig.  Itf. — Injured  Hand  (Extensor  Surface). 
Fig.    2. — Normal  Hand. 

Fig.  2a. — Injured  Hand  (Flexor  Siirface).     (The  conges- 
tion of  the  area  affected  by  the  iiaralysis  is  well 
rendered. )   ( See  also  Fig.  42  and  the  skiagraph, 
Fig.  43.) 
Plate  28. — Deformed  Hand,  after  Accident  with  Circular  Saw.     (See 

skiagraph.  Fig.  50. ) 
Plate  29.— Fig.     1.— Loss  of  Little  Finger  and  Head  of  Fifth  Meta- 
carpal   Bone.      Adherent  Scar.      (The  fourth 
finger  can  be  only  jmrtly  flexed.)     (See  Fig. 
.-.1.  ) 
Fig.    2. — Showing    Star-shaped   Adherent    Scar  over  the 
Metacarpo])halangeal  Joint  of  the  Index-finger. 
(The  finger  is  slightlv  disjilaced  for\\'ard. ) 
Plate  30.— Fig-s.  1  and  !«.— Stiff  ]Middle  Finger  and  Loss  of  Part  of 

Distal  Phalanx  in  Consequence  of  Cai'- 
bolic  Acid  CTangrene. 
Fig.    2." — Paralysis  of  the  Uluar  Nerve  Due  to  Crushing  of 
the   Shoulder.      The    Median    Nerve   is  also 
Affected. 
Plate  31. — Sulxjutaneous  Kupture  of  the  Left  Semitendinosus. 
Plate  32.— Scars  of  the  Right  Thigh,  Right  Ilium,  and  Inner  Side  of 
the  Left  Thigh,  and  Loss  of  Left  Testicle.     (Good  re- 
covery from  very  severe  injuries. ) 
Plate  33. — Compression  Fracture  of  the  Upper  Extremity  of  the  Left 
Tibia  and   Fracture  of  the  Head   of   the  Fibula.     (See 
.skiagraph,  Fig.  75. ) 
Plate  34. — Genu  Valgum  Following  Fracture  of  the  Left  Leg  Near  the 
Knee.      (The  leg  appears  cyanotic.)      (See  skiagraph. 
Fig.  70. ) 
Plate  35. — Atro])hy  of  the  Left  Lower  Extremity  Following  Fracture 
of  the  Anterior  Border  of  the  Interosseous  Depression  on 
the  Lo^er  End  of  the  Tibia  and  Contusion  of  the  Leg. 
(See  sole-impressions,  Fig.  77.) 
Plate  36  — Pseudo-arthrosis  of  the  Left  Leg  after  Compound  Fracture. 
Cyanosis.     (Fig.  \h  shows  the  scar. )     (See  also  the  sole- 
impressions  in  Fig.  78. ) 
Plate  37. — Fig.    1. — Scars  in  the  Popliteal   Space,  .on  the  Calf,  and 
Around  the  Ankle  after  Recovery  from  Cellu- 
litis. 
Fig.    2. — Scars  on  Left  Leg  and  Ankle  after  Recovery  from 
a  Scald. 
Plate  38.- Fig.  1«. —Atrophy  of  the  Dorsum  of   the  Left  Foot  after 
Fracture  of  the  (!)s  Calcis. 
Fig.     1. — Normal  Foot. 
Fig.  2«. — Shows  the  Atrophy  of  the  Plantar  Surface. 


22 


COLORED   PLATES. 


Fig.  2. — Normal  Foot.  (See  also  the  sole-impressions, 
Fig.  97. ) 
Plate  39. — Fig.  1. — Loss  of  First  and  Second  Toes,  Contracture  of 
Third,  J'onrth,  and  Fifth  in  Extension  and 
Scars  on  P>oth  Sides  of  the  Foot,  in  a  Case  of 
Compound  Fracture  (Crushing)  of  the  Toes. 
(See  also  skiagraph,  Fig.  124,  and  the  sole- 
impressions,  Fig.  123. ) 

Fig.  2. — Case  of  Compound  Fracture  of  the  Metatarso- 
phalangeal Joint  of  the  Great  Toe,  Showing 
Adherent  Sear  and  Thickening  of  Joint.  (See 
skiagraph.  Fig.  125. ) 
Plate  40.— Fig.  1. — Scar  of  Dorsum  of  Foot  Adherent  to  the  Extensor 
Communis  I>revis. 

Fig.  2. — Traumatic  Ciul)-foot  Following  Fracture  and 
Unreduced  Dislocation  of  the  Astragalus. 
(See  skiagra])h,  Fig.  132,  and  sole-impressions, 
Figs.  133  and  134.) 


INTRODUCTION   TO  THE  AMER- 
ICAN EDITION. 


The  past  few  years  have  witnessed  an  appreciable  in- 
crease in  the  knowledge  of  diseases  induced  by  physical  in- 
jury and  mental  shock.  The  danger  to  workmen  in  special 
occupations  is  now  known  in  accurate  percentages.  The 
relative  value  of  causes  is  more  firmly  established.  Symp- 
toms and  their  significance  have  been  so  diligently  studied 
that  the  outcome  of  individual  diseases  can  be  foretold 
with  remarkable  exactness.  A  variety  of  causes  underlies 
this  advance.  Apart  from  the  onward  movement  of 
medicine,  accidents  as  causes  of  disease  occupy  a  place  of 
unprecedented  importance.  Every  year  over  four  thou- 
sand persons  are  killed  and  over  thirty-eight  thousand  are 
injured  on  railways  in  the  United  States  alone.  As  shown 
in  tlie  statistics  on  page  35  of  this  "Atlas,"  during  the 
year  1898  over  ninety-seven  thousand  workmen  insured 
under  the  German  law  sustained  injury.  In  the  nature 
of  things,  the  quantum  of  these  injuries  is  taken  to  the 
courts  for  determination.  There  we  find  the  subject  has 
attained  the  same  prominence  that  it  has  in  medicine. 
Court  calendars  are  everywhere  crowded  with  personal 
injury  cases,  and  negligence  law  now  has  reports  of  its 
own.  It  is  estimated  that  one-half  the  jury  trials  in  the 
State  of  New  York  concern  actions  for  personal  injuries. 
But  even  judicial  records  fail  to  reflect  the  real  activity  in 
this  branch  of  law,  since  for  one  litigated  claim  there  are 
at  least  eight  claims  settled  out  of  court. 

23 


24         INTRODUCTION  TO  THE  AMERICAN  EDITION. 

So  far  118  the  writer  is  iiware,  Germany,  by  the  passage 
of  the  hiw  insuring-  workmen  against  injury,  is  the  only 
country  which  has  attempted  to  deal  comprehensiycly 
with  the  problems  inyolyed.  An  epitome  of  this  law  is 
as  follows  : 

Workmen  and  em})loyees,  with  the  exception  of  those 
of  commercial,  of  domestic,  and  of  a  few  t)ther  callings, 
whose  annual  wages  do  not  exceed  2000  marks,  are  in- 
sured against  accidents  incident  to  their  vari(jus  occupa- 
tions. Such  persons,  injured  during  their  work,  are  en- 
titled to  free  medical  treatment,  and,  from  the  fourteenth 
week  after  the  accident,  to  an  indemnity  of  two-thirds  of 
their  wages,  payable  monthly.  This  applies  only  to  acci- 
dents occurring  at  the  time  of  working  ;  it  does  not  include 
industrial  diseases.  But  all  preexisting  diseases  which 
are  brought  into  activity  or  whose  course  is  hastened  by 
such  an  accident  must  be  indemnified  under  the  law.  In 
case  of  the  death  of  the  workman,  the  widow  is  entitled 
to  burial  expenses,  and  to  full  indemnity  for  herself  and 
her  children  until  the  latter  attain  the-  ao-e  of  fifteen 
years.  The  insurance  to  the  employees  is  given  and 
the  indenmity  paid  by  the  •' Berufsgenossenschaft" — that 
is,  by  an  association  of  the  employers  of  the  various 
trades.  The  establishment  of  tlie  amount  of  indemnity 
is  usually  based  ujion  a  medical  certificate  and  fixed  by 
the  Berufsgenossenschaft.  The  injured  workman  may 
appeal  from  this. 

If,  after  settlement,  an  important  change  in  the  injured 
person's  condition  takes  place,  the  indemnity  may  be  re- 
adjusted, either  to  the  advantage  of  the  workman  or  to 
that  of  the  employers. 

The  amount  of  indemnity  is  graded  in  accordance  with 
the  disability.  In  cases  of  total  disability  the  full  amount 
is  paid  ;  when  the  disability  is  ])artial,  only  a  part  of  the 
amount.  If  the  workman  is  (lisal)led  for  his  special  occu- 
pation, but   can  support  himself,  though  not  so   well,  at 


JNTRODUCTIOJsr  TO  THE  A3IER1CAN  EDITION.         25 

some  other,  jwynient  is  made  in  proportion  to  his  lessened 
earning  capaeity. 

Tlie  following  table  shows  approximately  the  propor- 
tionate indemnity  values  in  various  injuries  : 

Severe  head  iiijm-ies,  with  concussion  of  the 

brain 50  ^  to  100  % 

Epilepsy 50  ^«  to  100  % 

Slight  head  injnries  which  cause  headaches 

and  dizziness 30  5<;  to    35   % 

Loss  of  one  eye 25   ^'^  to    33j% 

"       both  eyes 100  % 

"       an    eye   Mhen    the  other  eye    A\as 
already  l)lind '.    .    .    .  100   % 

Deafness  in  one  ear  ^^■ith  partial  deafness  in 

the  other  (dynamite  explosion) 40  % 

Crushing  of  chest  with  fracture  of  ribs,  in- 
volving diaphragm  and  lungs      60  %  to    75  % 

Rupture  ;  one  side,  10 ;7^  ;  both  sides,  \'i^/( . 

All  ruptures  preventing  use  of  the  aljdom- 

inal  muscles 50  ^ 

Paralysis  of  the  extremities  following  frac- 
ture of  the  spine.  The  allowance  varies 
with  degree  of  disability. 

Paralysis  of  one  leg 70  % 

Pain  in  the  back,  diminishing  working 
capacity ....  20  % 

Loss  of  all  fingers  and  toes .  100  % 

Lo.ss  of  right  forearm  or  ujjper  arm    ....     75   %  to    HO   ^ 

Loss  of  left  forearm  or  upper  arm 66f  %  to    70  % 

' '     a  great  toe 10  % 

"      all  the  toes  of  one  foot 20  % 

"     one  foot         35  f<^-  to    50  % 

All  affections  of  the  lower  extremities  neces- 
sitating the  use  of  a  crutch  or  a  cane    .    .    50  ^^  to    75  % 

This  law  insuring  workmen  against  injury  was  origin- 
ally passed  in  1884;  since  then  it  has  received  various 
revisions  and  extensions.  It  lays  on  pliysieians  gener- 
ally the  obligation  to  be  familiar  with  traumatic  cases, 
and  it  has  proved  to  be  a  great  stimulus  to  the  study  of 
this  branch  of  medicine  in  Germany.  And  while  the 
German  working-man  has  derived  nuich  benefit  from  its 
wise  provisions,  German  medicine  has  also  profited  by  the 


26         INTRODUCTION  TO  THE  AMERICAN  EDITION. 

means  it  offers  for  the  observation  of  how  the  human  body 
reacts  to  various  kinds  of  injuries. 

The  salient  difference  in  the  systems  as  applied  in  Ger- 
many and  in  this  country  is  that  the  damages  under  the 
German  law  are  determined  by  an  harmonious  principle 
applied  whether  the  employer  or  the  employee  is  negligent. 
Under  the  German  method  every  factor  except  the  extent 
of  the  injury  is  fixed  and  uniform.  In  the  United  States 
nothing  is  fixed  except  the  abstract  principles  of  law  as 
set  forth  in  the  judge's  charge  to  the  jury.  A  hysteric 
girl,  without  responsibilities  and  without  the  capacity  for 
self-support,  may  receive  a  verdict  for  some  trivial  mishap 
very  much  in  excess  of  that  given  a  working-man  for  in- 
juries which  disable  him  for  life. 

One  of  the  wisest  provisions  of  the  German  law  is  that 
the  insurance  allowance  may  be  •  diminished  or  increased 
according  as  the  injured  person  gets  better  or  worse  with 
time.  It  insures  justice  to  both  workman  ami  employer, 
and  practically  does  away  with  the  question  of  exaggera- 
tion. In  America,  when  the  plaintiff  gets  his  money  his 
case  is  judicially  at  an  end.  His  disease  may  become 
worse,  but  he  is  entitled  to  no  further  indemnity  ;  or  his 
condition  may  improve  without  his  being  called  upon  to 
make  any  return  of  the  proceeds.  Yet  the  verdicts  are 
notoriously  capricious,  often  unjustly  reflecting  the  sex 
and  personality  of  the  injured. 

The  contingent  fee  system,  so  far  as  M'orkmen  are  con- 
cerned, is  avoided  by  the  German  law.  It  is  a  system 
that  tends  to  make  the  lawyer  rather  more  than  an  advo- 
cate, and  the  physician  rather  more  than  an  expert.  These 
sometimes  so  far  exceed  the  limits  of  their  respective 
callings  as  to  become  partners  with  the  litigant,  whose 
poverty  is  the  real  cause  of  the  system.  It  is  but  a  step 
further  to  the  "  runners "  and  the  merciless  pursuit  of 
injured  persons  who  may  iiave  claims  for  damages  to 
bring.  The  adoption  in  America  of  some  such  plan  as 
the  one  that  Germany  has  found  feasible  for  the  past  six- 


INTRODUCTION  TO  THE  A3IEBICAN  EDITION.         27 

teen  years  Mould  unquestionably  be  mutually  beneficial  to 
both  employers  and  employees.  The  middleman,  it  is 
true,  would  suffer,  for  the  money  which  now  goes  to  him 
would  remain  with  the  companies  or  would  go  to  the 
maintenance  of  disabled  wage-earners. 

Important  as  this  question  is  in  its  sociologic  and  legal 
connections,  its  true  inwardness,  so  far  as  the  medical  man 
is  concerned,  is  in  the  added  requirements  that  the  promi- 
nence of  traumatism  in  general  pathology  lays  upon  him. 
Now,  as  never  before,  it  is  imperative  that  every  practi- 
tioner be  familiar  with  the  effects  of  injury  on  the  body  in 
health  and  in  disease. 

To  express  the  l)ranch  of  medical  science  which  has  to 
do  with  this  relationship,  the  Germans,  with  their  usual 
fertility  of  nomenclature,  have  created  the  term  "  Unfall- 
heilkunde."  Unftdlheilkunde  is  not,  of  course,  a  distinct 
branch,  such  as  surgery  or  ophthalmology.  It  is  in  one 
sense  broader  than  any  one  branch,  as  it  embraces  them 
all  ;  and  it  deals  with  all  from  the  common  standpoint  of 
injuiy  as  a  cause.  In  this  respect  it  can  justly  claim  a 
place  among  the  departments  of  medicine  with  distinctive 
characteristics.  For  example,  in  traumatic  cases  causes, 
both  predisposing  and  exciting,  demand  special  considera- 
tion. The  first  may  have  been  acquired,  or  may  have  been 
transmitted  through  generations  as  mental  or  physical  de- 
fects. Bodily  infirmities,  impairment  of  one  or  more  of 
the  special  senses,  mental  deficiencies,  diseases  such  as 
epilepsy  or  general  paresis, — in  short,  anything  and  every- 
thing that  renders  the  individual  more  exposed  to  in- 
jury or  less  capable  of  taking  care  of  himself, — must  be 
reckoned  among  the  predisposing  causes  of  traumatic 
diseases. 

Familiarity  with  exciting  causes  falls  witliin  the  pro- 
vince of  special  workers.  We  turn  naturally  to  the  rail- 
way surgeon  for  detailed  information  as  to  the  physical 
effects  of  railway  injuries,  to  the  ophthalmologist  for  an 
intimate  knowledge  of  traumatic  lesions  of  the  eye,  and  to 


28         INTRODUCTION  TO  THE  AMERICAN  EDITION. 

the  neurologist  for  an  exj)]anation  of  the  ]x'culiar  disorder.s 
of  recent  date,  known  as  the  traumatic  neuroses,  which  so 
frequently  result  from  the  combined  influence  of  })]iysical 
injury  and  nervous  shock. 

It  must  not  be  forgotten  that  the  relationship  between 
traumatisms  and  disorders  that  are  not  inmiediately  surgi- 
cal is  often  very  obscure  and  difficult  of  demonstration. 
In  many  cases  the  relationshij)  is  incontestable,  though 
how  it  is  brought  about  is  uncertain  ;  in  others  it  can 
hardly  be  said,  from  our  present  knowledge,  to  be  more 
than  probable.  This  is  especially  the  case  wdien  there  is 
a  long  time-interval  between  the  receipt  of  the  injury  and 
the  first  appearance  of  symptoms. 

Diagnosis  in  traumatic  cases  means  much  more  than  a 
simple  recognition  of  the  particular  injury  or  disease  that 
has  an  accident  as  its  starting-point.  It  means  the  type  of 
man  affected  by  it  quite  as  much  as  the  injury  itself,  for  what 
in  one  individual  would  be  little  more  than  an  inconveni- 
ence would  in  another  be  a  cause  of  death.  Diagnosis, 
therefore,  implies  an  estimation  of  the  resistance  of  the 
individual  quite  as  much  as  of  the  extent  of  immediate 
injury  ;  and  the  ability  to  estimate  resistance  implies  not 
only  a  knowledge  of  general  physiology,  but  also  a  famil- 
iarity with  the  social,  familiary,  and  personal  conditions 
that  favor  or  discourage  the  processes  of  recuperation  and 
rej)air.  It  is  the  ])hysician  who  considers  the  problem 
l)efore  him  from  this  point  of  view  who  will  most  often 
find  his  prognosis  verified  by  subsequent  events. 

The  question  of  simulation  naturally  comes  up  under 
diagnosis.  It  is  one  with  which  the  surgeon  has  little  to 
do.  A  man  can  not  simidate  a  l)roken  leg,  and  self- 
inflicted  disfigurements  and  mutilations,  while  occasionally 
heard  of  in  armies  and  prisons,  are  rarely,  if  ever,  at- 
tempted in  personal  injury  claims.  In  the  obscurer 
internal  diseases,  and  es]iecially  in  those  afl^ecting  the  ner- 
vous system,  simulation  may  be,  and  sometimes  is,  suc- 
cessfully carried  out ;  but  even  in  nervous  diseases  the 


INTRODUCTION  TO  THE  AMERICAN  EDITION.  29 

subject  has  received  more  prominence  than  it  deserves. 
Nearly  all  American  and  European  writers  agree  that  the 
creation  of  symptoms  for  the  purpose  of  making  money 
out  of  them  is  rarely  met  with.  Golebiewski  estimates 
simulation  in  German  workmen  at  two  per  cent.  Much 
has  been  written  on  the  means  of  detecting  simulation.  It 
may  be  sunmied  up  in  this  :  a  definite  organic  type  of  dis- 
ease,— such  as  paralysis, — to  be  feigned  in  a  way  to  de- 
ceive a  physician  who  is  careful,  skilful,  and  reasonably 
resourceful,  is  practically  impossible.  On  the  other  hand, 
there  are  diseases,  such  as  epilepsy  or  neurasthenia,  the 
existence  of  which  can  not  be  denied  because  the  exam- 
ination of  the  patient  is  negative.  In  such  cases,  if  the 
patient's  story  as  to  his  symptoms  is  to  be  disproved, 
he  must  be  kept  under  constant  observation.  In  the 
United  States  such  a  course  is  always  difficult  and  often 
impossible. 

The  exaggeration  of  symptoms  actually  present  is  a 
much  more  important  consideration  in  accident-cases  than 
simulation.  It  is  found  especially  in  functional  ner- 
vous diseases.  No  rules  for  the  estimation  of  the  degree 
of  exaggeration  in  any  given  case  are  possible  ;  but  the 
experienced  physician  is  usually  able  to  tell  with  a  fair 
degree  of  accuracy  how  far  symptoms  are  magnified,  and 
how  far  the  magnification  is  voluntary  or  unconscious, 
depending  upon  the  personal  peculiarity  of  the  patient. 

The  medicolegal  relations  of  diseases  caused  by  acci- 
dents form  the  most  important  department  of  "  Unfall- 
heilkunde."  They  are  the  sum  of  all  the  considerations 
previously  mentioned,  plus  their  position  in  law.  In  es- 
tablishing them,  account  must  be  taken  of  the  individual's 
previous  earning  capacity  ;  of  his  predisposition  ;  of  the 
suffering  through  which  he  has  gone,  as  well  as  that  which 
is  still  in  store  for  him  ;  of  his  actual  incapacity,  and  the 
probability  of  its  increasing,  remaining  stationary,  or  be- 
coming less.  These  and  many  other  questions  must  be 
considered  from  a  purely  medical  point  of  view,  for  it 


30         INTRODUCTION  TO  THE  A3IERICAN  EDITION. 

lies  beyond  our  province  to  enter  into  legal  questions, 
although  every  physician  who  has  to  do  with  traumatic 
cases  would  profit  by  a  knowledge  of  law. 

Enough  has  been  said  to  show  the  importance  and  diffi- 
culties of  the  study  of  these  cases.  The  life  of  a  science, 
as  of  a  people,  is  quickly  mirrored  in  its  literature,  and 
medical  literature  has  not  failed  to  respond  to  the  demand 
for  collated  and  progressive  information  concerning  trau- 
matic diseases.  The  response  has  taken  the  form  of 
various  periodicals  and  numberless  monographs,  but  the 
present  book  is  the  first  to  attempt  a  treatment  of  the 
whole  subject. 

In  the  "  Atlas  and  Epitome  of  Diseases  Caused  by  Ac- 
cidents "  Dr.  Golebiewski  has  given,  in  brief  and  succinct 
form,  the  present  knowledge  of  this  important  branch  of 
medicine.  As  is  shown  by  the  number  and  variety  of 
illustrative  cases,  his  statements  are  based  on  an  extensive 
personal  experience,  and  the  text  embodies  a  comprehen- 
sive review  of  the  literature.  He  treats  the  subject  chiefly 
from  the  point  of  view  of  ultimate  results,  and  has  made 
an  invaluable  collection  of  facts  to  show  the  degree  of 
functional  disability  that  may  be  expected  from  a  given 
injury.  No  department  of  medicine  could  adapt  itself 
better  to  illustration,  and  the  illustrations  in  the  "  Atlas  " 
have  been  chosen  with  discrimination  and  executed 
with  skill.  The  collection  of  skiagraphs  is  ])articularly 
valuable.  It  is  a  great  pleasure  to  be  afforded  this 
opportunity  of  introducing  the  book  to  the  English- 
speaking  public.  It  is  a  reliable  and  graphic  presenta- 
tion. To  the  general  practitioner  it  should  serve  as  a 
ready  book  of  information  and  reference,  and  to  the 
specialist,  in  addition  to  furnishing  facts  outside  his  im- 
mediate sphere,  it  should  suggest  new  lines  of  inquiry. 

It  should  also  have  a  wide  field  of  usefulness  in  the 
legal  profession.  The  anatomic  and  physiologic  sum- 
maries at  the  beginning  of  the  various  sections,  togetlior 
with  the  illustrations,  should  make  the  text  intelligible  to 


INTRODUCTION  TO  THE  A3IERICAN  EDITION.         31 

nonmedical  readers  ;  and  a  book  with  these  qualifications, 
on  this  subject,  will  certainly  be  welcomed  by  lawyers. 

In  preparing  the  American  edition  I  have  taken  the 
liberty  of  omitting  part  of  the  German  text  and  some 
of  the  cases,  and  of  adding  a  few  notes.  For  nearly 
all  of  the  translation  I  am  indebted  to  Dr.  Marion 
McD.  Grady. 

Pearce  Bailey. 

New  Yokk,  June,  1900. 


PART  I. 

I.  GENERAL   CONSIDERATIONS. 

I.  THE  CAUSES  OF  ACCIDENTS. 

The  deteriuiuing  causes  of  accidents  may  be  conveni- 
ently divided  int<j  internal  and  external.  The  internal 
causes  are  to  be  sought  in  the  individuality  and  condition 
of  health  of  the  victim.  To  this  category  belong  :  (1) 
Carelessness,  recklessness,  failure  to  observe  danger  notices, 
inappropriate  and  clumsy  movements,  etc.  (2)  General 
ill  health.  (3)  Acute  and  chronic  diseases  and  infirmi- 
ties. 

1.  Accidents  caused  by  carelessness  and  recklessness 
need  not  be  considered  here  ;  but  the  injuries  to  healthy 
persons  brought  about  through  inappropriate  and  clumsy 
or  forced  movements  deserve  mention.  It  will  be  suffi- 
cient to  enumerate  the  following  :  Fractures  occurring  in 
aged  people  from  very  trivial  causes  ;  fractures  of  the 
patella  caused  by  overflexion  of  the  knee-joint,  the  tension 
on  the  ligament  })ulling  away  a  portion  of  the  bone ;  frac- 
tures of  the  olecranon  process  caused  by  violent  over- 
extension of  the  arm. 

2.  General  ill  health  impairs  the  soundness  and  power 
of  resistance  of  the  body,  a  fact  which  becomes  still  more 
evident  in — 

3.  Acute  diseases.  With  these  must  be  classed  acute 
alcoholic  intoxication,  which,  as  is  well  known,  is  responsi- 
ble for  many  casualties. 

Chronic  diseases  may  lead  to  various  accidents,  often 
of  a  very  serious  nature,   causing  permanent  impairment 
3  33 


34  DISEASES  CAUSED  BY  ACCIDENTS. 

of  health  or  even  death.  The  most  insignificant  causes 
sometimes  suffice  to  produce  a  severe  physical  injury,  to 
aggravate  a  preexisting  disease,  or  to  call  a  latent  malady 
into  activity.  As  examples  of  such  disproportion  between 
cause  and  effect  we  may  instance  the  fractures  that  occur 
in  locomotor  ataxia,  syphilis,  tuberculosis,  sarcomatosis, 
etc.  ;  also  the  hemorrhages  from  the  lungs  and  the  de- 
velopment of  pulmonary  tuberculosis  consequent  upon 
lifting  comparatively  light  weiglits.  Chronic  alcoholism 
also  acts  as  a  predisposing  cause  of  injuries.  The  dimin- 
ished soundness  and  power  of  resistance  of  the  body  in 
chronic  diseases  furnishes  a  sufficient  explanation  of  the 
frequent  occurrence  of  accidents  in  these  cases. 

The  external  causes  of  accidents  may  be  (1)  general 
or  (2)  special. 

1.  The  general  causes  comprise  :  (a)  Influences  of 
weather ;  (6)  influences  of  season ;  (c)  various  causes  of 
accidents  that  are  not  considered  to  be  accidents  of  a 
trade  or  profession  according  to  the  provisions  of  the 
Accident  Insurance  Law. 

Under  a  we  place  the  unfavorable  influences  of  rain, 
snow,  frost,  long-continued  cold,  excessive  heat,  storms, 
and  severe  thunder-storms,  through  which  the  danger  of 
accidents  is  heightened. 

Under  b  we  consider  the  various  influences  of  the  sea- 
sons, of  holidays  and  festivals,  and  of  special  days  of  the 
week  :  as,  for  instance,  Monday  in  respect  to  the  building 
trade  ("  blue  Monday  "). 

(c)  This  third  division  of  the  general  causes  of  acci- 
dents is  made  up  of  a  variety  of  special  causes  which  com- 
prise class  2.  The  distinction  is  made  chiefly  with  refer- 
ence to  the  matter  of  insurance,  which  is  collectable  only 
when  the  individual  is  injured  during  the  actual  perform- 
ance of  the  duties  of  his  calling. 

2.  Special  Causes  of  Accidents. — This  class,  as 
already  indicated,  includes  all  the  causes  of  accidents 
occurring  as  incidental  to  trades  and  professions. 


STATISTICS  OF  ACCIDENTS.  35 

2.  ACCIDENTS. 

Accidents  vary  according  to  the  nature  of  the  work  per- 
formed by  tiie  injured  person.  Each  trade  has  its  char- 
acteristic set  of  injuries.  The  accidents  to  which  miners 
are  subject,  for  instance,  are  of  a  different  type  from  those 
met  with  in  weavers ;  while  carpenters  and  clothing 
makers  suffer  from  accidents  equally  dissimilar  in  char- 
acter. The  German  State  Insurance  Bureau  has  published 
a  table  of  accidents  for  statistical  purposes  for  the  use  of 
all  the  trades-unions.  We  quote  the  most  important 
headings : 

Accideuts  couuected  with — 

Motors. 

Elevators,  cranes,  and  derricks. 

Steam  boilers,  steam  pipes,  and  steam  cookiug  apparatus  ;  explo- 
sions and  explosives  (explosions  of  powder  and  dynamite). 

Inflammable,  hot,  and  caustic  materials,  gases,  and  fumes. 

Collapse  of  buildings,  etc.,  blows  from  falling  objects. 

Falls  from  ladders,  stairs,  etc.  ;  falls  into  openings  or  excavations. 

Loading  and  unloading  of  hods. 

Vehicles  (being  run  over  by  wagons  and  carts  of  any  sort). 

Kailroads  (being  run  over). 

Shipping  and  transportation  by  water  (falling  overboard). 

Animals  (kicks,  bites,  blows),  including  all  riding  accidents. 

Tools,  including  simple  tools  (hammer,  axe,  spade,  hoe). 

To  the  special  causes  belong  also  the  accideuts  that  occur  as  the 
result  of  overexertion  while  at  work. 

3.  STATISTICS  OF  ACCIDENTS. 

In  1898,  6,042,618  individuals  were  insured  in  65  industrial  trades- 
unions.  Of  this  number  41,746  suffered  accidents  :  38,788  were  men, 
1,572  women,  1,209  boys,  and  177  girls  under  sixteen  years.  The 
proportion  is,  therefore,  6.91  accidents  to  every  1000  people  insured. 
In  the  agricultural  trades-unions,  11,189,071  were  insured  ;  of  these, 
45,433  suffered  accidents — or  4.06  to  the  1000.  If  the  industrial  and 
agricultural  trades-unions  are  considered  together,  the  jiroportion  is 
5.06  accident-cases  to  the  1000  insured. 

The  frequency  of  accidents  in  the  different  ages  and  sexes  is  stated 
in  the  statistics  published  in  1893  by  the  State  Insurance  Bureau. 
According  to  these  statistics,  2.73  %  of  the  accident-cases  concern 
children  under  sixteen  years  ;  8.74  %  were  between  sixteen  and  twenty 
years  of  age,  while  88.53  %  were  over  twenty  years  of  age. 

The  causes  of  the  accidents  affecting  children  under  sixteen  years 
were  chiefly   awkwardness    and    carelessness,  etc.    (23.85  ^),    dan- 


36  DISEASES   CAUSED  BY  ACCIDENTS. 

gerous  work  (19.04%),  a  Lack  of  arrangements  for  protection  (16.74%), 
and  disobedience  to  rules,  etc.  (10.55%).  The  causes  at  work  iu  the 
cases  Ijetween  sixteen  and  twenty  years  were  dangerous  work  (30.30%), 
awkwardness  and  carelessness,  etc.  (18.84  %),  a  lack  of  arrangements 
for  protection  (13.04%),  and  disobedience  to  rules,  etc.  (9.67%).  The 
causes  acting  in  the  cases  over  twenty  years  of  age  were  dangerous 
work  (45.46%),  awkwardness  and  carelessness  (16.03%),  a  lack  of 
arrangements  for  protection  (10.2:2%),  defective  machinery,  etc., 
(7.14%). 

The  causes  of  the  accidents  among  the  male  workers  were  chiefly 
dangerous  work  (44.36  % ),  awkwardness,  carelessness,  etc.  (16.49  %), 
a  lack  of  arrangements  for  protection  (10.50  %).  Among  the  female 
cases  the  causes  were  dangerous  work  (18.92% ),  disobedience  to  rules, 
etc.  (18.60%),  awkwardness  and  carelessness,  etc.  (16.64%),  and  a  lack 
of  arrangements  for  protection  (14.19  %). 

Tlie  percentage  of  accidents  due  to  dangerous  work  shows  that  the 
work  of  male  employees  is  much  more  dangerous  in  character  than 
that  of  female  emplo^'ees.  The  decidedly  high  tigures  of  the  causes 
involving  a  fault  on  the  part  of  the  employee,  especially  iu  relation 
to  disobedience  to  rules,  bring  us  to  the  conclusion,  however,  that 
female  workers  ])ay  less  attention  to  rules  than  male  workers.  The 
percentage  of  accidents  due  to  awkwardness,  carelessness,  etc.,  is,  on 
the  other  hand,  about  equal  for  the  two  sexes,  showing  that  female 
workers  are  not  more  deficient  in  caution  and  skill  than  male 
workers. 

Fatal  accidents  were  caused  in  a  large  proportion  (44.15%)  of  the 
cases  by  dangerous  work  :  awkwardness  and  carelessness,  etc.,  were 
the  cau.ses  in  9.98%  of  the  cases  ;  deficient  machinery,  etc.,  in  8.23% 
of  the  cases ;  a  lack  of  arrangements  for  protection  iu  7.44%,  and  dis- 
obedience to  rules  in  6.66%. 

The  influence  of  the  seasons  is  important,  especially  in  relation  to 
those  who  work  out  of  doors,  among  whom  the  percentage  of  accidents 
is  highest  in  the  winter  months.  More  accidents  occur  in  the  winter 
months  than  in  tlie  summer  ;  in  fact,  in  the  majority  of  tlie  trades  and 
industries.  The  fact  tliat  the  building  trades  and  the  inland  shipping 
trades  show  a  low  percentage  of  accidents  in  the  winter  is  explained 
by  the  decrease  in  the  activity  of  these  trades  at  that  season.  The 
relative  percentage  of  accidents  in  all  classes  of  out-of-door  workers  is 
higher  in  the  winter  season,  and  the  cases  are,  on  the  average,  more 
serious  than  those  that  occur  in  the  summer. 

Certain  days  of  the  week  also  have  an  influence  on  the  occurrence 
of  accidents  iu  a  number  of  industries.  Accidents  are  apt  to  occur  on 
Mondays  in  the  building  trade  and  among  drivers  ;  and  on  Saturday 
al'ternoon  in  the  weaving  trade.  We  must,  however,  not  accept  these 
figures  with  reservation.  Many  accidents  among  drivers  which  happen 
on  Saturday  night  or  on  Sunday  are  not  reported  until  Monday.  The 
publication  of  the  State  Insurance  Bureau  does  not  discu.ss  the  causes 
underlying  tlie  increased  number  of  accidents  occurring  on  Monday. 
We  are,  nevertheless,  justified  in  a.ssuming  that  the  fatigue  due  to 
Sunday's  iileasures,  especially  to  excessive  drinking,  is  the  chief  cause. 


GENERAL  CONSIDERATIONS.  37 

The  time  of  day  often  has  an  influence  of  no  small  importance 
in  the  causation  of  accidents  ;  tlie  latter  are  apt  to  occur  late  in  the 
day,  when  the  worker  is  latigued.  Fatigue  must  not,  however,  be 
looked  upon  as  the  chief  exciting  cause  oi  accidents.  It  is  wisest  to 
avoid  generalizations  as  to  tliis  point,  and  to  examine  tlie  conditions 
obtaining  in  the  various  industries.  We  will  tind  that  accidents  are 
influenced  in  their  occurrence  by  definite  conditions  often  dependent 
upon  the  peculiar  nature  of  a  certain  trade  :  under  one  set  of  condi- 
tions most  accidents  occur  in  the  morning,  wliile  under  another  set 
they  are  most  frequently  observed  in  the  afternoon. 


4.  FATAL  CASES. 

According  to  the  statistics  of  the  State  Insurance  Bureau  there  were, 
in  the  ten  years  between  1886  and  1896,  59,750  fatal  cases  of  accident 
among  a  total  of  516,762  accidents — or  0.38% .  These  figures  cover  all 
trade-s-union  insurance,  but  not  outside  insurance  companies. 

In  tlie  years  between  1886  and  1895  fatal  accidents  among  the  in- 
dustrial trades-unions  occurred  in  the  proportion  of  0.77  to  1000  mem- 
bers insured. 

The  following  table  shows  the  comparative  frequency  of  fatal  acci- 
dents among  industrial  and  agricultural  workers  : 

Industrial      ,      ■     ,,       , 
Form^AccUent.  Trades-       ^^^^s. 

unions. 

1.  Burns,  scalds,  action  of  caustics  .    .    .    1.34%  0.05% 

2.  Wounds,  contusions,  fractures,  etc.  : 

(rt)  of  arms  and  hands 0.63"  0.43" 

(6)  of  legs  and  feet 1.19"  0.94" 

(c)  of  head  and  neck 4.33"  2.94" 

{(l)  of  trunk 3.25"  3.85" 

{e)  of  several  parts  of  body  together    2.38"  3.85" 

(/)  of  whole  body 16.78"  10.02" 

3.  Suffocation 0.71"  0.20" 

4.  Drowning 0.92"  0.24" 

5.  Freezing  and  various  causes      ....  0.10"  0.10" 

6.  Stroke  of  lightning 0.31  " 

7.  Sunstroke 0.31  " 


5.    GENERAL   CONSIDERATIONS    REGARDING   TRAU= 
MATISM    AND  TRAUMATIC    DISORDERS. 

The  effects  of  traiimatisra  on  tlie  human  organism  may 
be  manifested  either  by  local  or  general  symptoms.  In 
the  former  case  external  signs  of  injury  are  almost  always 
evident ;  there  may  be  severe  general  symptoms,  on  the 


38  DISEASES  CAUSED  BY  ACCIDENTS. 

other  hand,  without  visible  bodily  injury,  or  local  and 
general  symptoms  may  be  observed  simultaneously. 

The  occurrence  of  purely  general  symptoms  after  trau- 
matism is  strikingly  illustrated  by  the  serious  condition 
described  under  the  name  of  shock.  A  discussion  of  its 
symptomatology  would  be  out  of  place  here.  We  should 
bear  in  mind,  however,  that  shock  may  follow  all  forms 
of  local  traumatism,  including  operations,  or  be  caused  })y 
general  traumatism — as,  for  instance,  concussions  received 
in  railroad  accidents.  It  may  even  be  brought  on  by 
fright  alone  (psychic  shock). 

General  symptoms  predominate  also  in  cases  of  heat- 
prostration  and  sunstroke.  While  the  general  symptoms 
of  a  person  suffering  from  the  effects  of  a  stroke  of  light- 
ning are  usually  severe,  characteristic  local  signs  are  not 
lacking. 

The  local  symptoms  of  traumatism  vary  according  to 
the  part  of  the  body  affected.  Personal  equation  must 
also  be  considered.  Analogous  injuries  produced  under 
precisely  similar  conditions  may  differ  widely  in  their 
effects  on  two  different  individuals. 


II.  GENERAL  CONSIDERATIONS  REGARDING 
PHYSICAL  INJURIES. 

I.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE  SKIN. 

Contusions  ^  of  the  skin  consequent  upon  kicks,  blows, 
or  falls  usually  heal  in  a  short  time  without  serious 
sequels.  The  same  is  true  of  light  cases  of  crushing  of 
the  skin.i      Rapid  absorption  of  the  blood  extravasations, 

'  A  distinction  is  made  throughout  this  ])ook  l)etween  contusions 
and  the  crushing  of  a  part.  By  contusion  is  meant  the  injury  caused 
by  a  fall,  blow,  or  kick  ;  and  by  crushing,  the  effects  of  two  or  more 
opposing  forces  bearing  on  the  part,  as  illustrated  by  cases  of  individu- 
als caught  between  moving  objects  or  under  a  falling  wall  or  embank- 
ment. 


THE  SKIN.  39 

whether  large  or  small,  is  induced  by  massage.  In  seri- 
ous cases  of  crushing,  on  the  other  hand,  the  process  of 
healing  is  apt  to  be  a  slow  one. 

A  break  in  the  continuity  of  the  skin  results  in  the  for- 
mation of  a  wound,  and  as  wounds  play  a  highly  impor- 
tant part  in  the  history  of  accident-cases,  we  are  justified 
in  discussing  their  different  forms  and  origin  in  this  place. 

Incised  wounds  may  be  caused  by  sharp  instruments  or 
by  sharp  materials  of  trade,  such  as  glass,  tin,  slate, 
pointed  stones,  etc.  The  prognosis  is  better  in  the  former 
instances  than  in  the  latter,  since  there  is  always  danger 
of  foreign  bodies  remaining  in  the  wounds  that  are  pro- 
duced by  the  materials  of  trade.  Wounds  caused  by  ma- 
chines, such  as  circular  saws  and  the  like,  are,  on  the  other 
hand,  often  of  a  very  serious  nature,  resulting  in  the  mu- 
tilation or  loss  of  several  fingers  or  phalanges.  Total  dis- 
ability for  self-support  is  very  apt  to  be  the  result  in  such 
cases. 

Severe  incised  wounds  caused  by  blows  of  a  hatchet, 
ax,  or  scythe  often  reach  so  deep  as  to  injure  the  bone, 
and  are  apt  to  leave  scars  which  interfere  with  the  func- 
tional action  of  the  part. 

The  punctured  wounds  which  we  need  to  consider  are 
those  caused  by  sharp-pointed  instruments  or  materials  of 
trade,  such  as  chisels  and  iron  wire,  respectively. 

Lacerated  wounds  are  esjjecially  serious,  because  of 
their  liability  to  infection,  and  because  the  ragged  edges 
of  the  wounds  are  a  common  form  of  iujury  in  the  build- 
ing and  slate-roofing  trades  and  in  those  concerned  in 
the  manufacture  of  wooden  articles ;  they  are  caused  by 
protruding  nails,  sharp  edges  of  slate,  splinters,  etc. 
Indirectly,  they  may  be  caused  by  overtension  of  the 
skin,  when  this  is  atrophic  or  cicatricial — on  the  extensor 
surface  of  the  knee-joint,  for  instance.  Occasionally, 
this  accident  may  occur  when  the  skin  is  normal,  as  de- 
scribed recently  l)y  J-  Riedinger. 

Wounds  caused  by  crushing-  of  the  parts  are  also  slow 


40  DISEASES  CAUSED  BY  ACCIDENTS. 

to  heal,  either  because  of  the  ragged  edges  of  the  wound 
or  in  consequence  of  the  entrance  of  infectious  material  at 
the  time  of  the  injury.  As  a  rule,  the  skin  does  not  suf- 
fer alone ;  the  deeper  structures,  even  the  bone,  are  very 
frequently  involved,  and  are  always  so  in  severe  cases,  as 
when  the  individual  is  struck  by  falling  beams,  ii'on 
plates,  granite  blocks,  or  is  caught  between  cog-wheels. 
It  is  hardly  necessary  to  state  that  the  infectious  bacteria 
find  an  easy  entrance  into  wounds  of  this  kind. 

BuIlet=wounds  play  but  little  part  in  the  subject  with 
which  we  are  here  concerned.  Wounds  produced  by  ex- 
plosions— by  blasting  in  mines  and  quarries — are,  on  the 
other  hand,  often  met  with.  Foreign  substances  are  likely 
to  be  carried  into  the  tissues,  adding  a  further  element  of 
danger  to  that  attaching  to  any  open  wound. 

The  insignificant  origin  of  the  majority  of  infected 
wounds,  and  the  great  danger  of  permanent  impairment 
or  loss  of  functional  power  which  they  entail,  make  a 
clear  understanding  of  the  subject  of  importance  to  us. 

Infected  wounds  necessitate  a  longer  course  of  treatment 
than  noninfected  wounds,  and  their  prognosis  is  always 
less  favorable.  Sometimes  the  process  of  healing  is  very 
protracted. 

In  the  great  majority  of  cases  the  infections  process 
begins  in  a  trifling  wound  of  a  finger,  caused  by  a  prick, 
a  scratch,  or  the  entrance  of  a  splinter.  The  lower  ex- 
tremity is  seldom  affected.  The  wound  does  not  bleed, 
and  is  often  scarcely  discernible.  The  anatomy  of  the 
skin  furnishes  the  explanation  of  the  serious  consequences 
of  such  an  injury  :  if  the  wound  reaches  the  ]Mal})ighian 
layer  of  the  epidermis,  the  door  is  opened  to  the  entrance 
of  infection.  The  injury  being  so  slight,  it  does  not  occur 
to  a  workman  to  put  down  his  work.  If  he  feels  uneasy 
and  speaks  to  his  employer  about  it,  he  is  likely  to  be  told 
not  to  stop  work  for  such  a  trifle.  So  the  splinter,  for  ex- 
ample, is  removed  by  the  workman  himself,  who  then  ties 
a  dirty  rag  around  his  finger  and  resumes  work.      Three 


WOUNDl^  OF  THE  SKIN.  41 

days  later  fever,  with  pain  and  swelling  of  the  part, 
usually  begins ;  the  pain  rapidly  increases  aiid  soon  runs 
from  the  linger  up  the  hand  and  arm  to  the  axilla  :  the 
whole  hand  is  red  and  swollen,  and  hot  and  resistant  to 
the  touch.  AVe  have  to  deal,  in  short,  with  a  phlegmon- 
ous inflammation,  or,  in  popular  language,  with  a  case  of 
"  blood-poisoning."  The  infectious  germs  may  have  en- 
tered at  the  time  of  the  injury,  or  afterward,  through  the 
wound.  The  incubation  period  is  usually  al)out  three 
days  :  it  may,  however,  be  as  short  as  twenty-four  hours, 
or  as  long  as  three  weeks. 

For  the  cases  not  seen  by  the  physician  until  well  devel- 
oped, a  bad  prognosis  in  respect  to  functional  power  nuist 
almost  always  be  made.  Repeated  operative  procedures 
on  fingers  and  hands  are  generally  called  for,  which,  as  a 
rule,  result  in  permanent  disability  of  the  part.  The 
fingers  are  usually  left  quite  stiff,  while  the  hand,  fingers, 
and  forearm  are  lined  with  scars ;  the  skin  feels  cold,  and 
is  often  cyanotic  (glossy  skin). 

As  already  stated,  infected  wounds  are  almost  always 
found  on  the  hands.  In  cases  of  involvement  of  the 
thumb  or  the  little  finger  the  condition  is  especially 
serious,  for  the  reason  that  the  tendon-sheaths  of  both 
communicate  with  the  common  tendon-sheath  of  the 
flexors  of  the  fingers.  The  infected  wounds  that  occa- 
sionally occur  on  the  lower  extremities  are  apt  to  call  for 
very  extensive  operations,  resulting  in  a  growth  of  cica- 
tricial tissue  which  impairs  the  usefulness  of  the  limb, 
especially  when  located  about  the  principal  joints. 

Slight  abrasions  of  the  skin  of  the  leg  when  the  latter 
is  the  seat  of  varicose  veins  quite  frequently  serve  as  the 
starting-point  of  a  suppurative  infection,  no  attention 
being  paid  to  the  injury  before  the  development  of  the 
severe  pain  and  fever  which  accom]xiny  the  inflammation. 
While  the  prognosis  as  to  usefulness  of  the  parts  is  usually 
unfavorable,  it  is  rarely  so  in  regard  to  life,  although  these 
cases  do  occasionally  end  fatally. 


42  DISEASES  CAUSED  BV  ACCIDENTS. 

The  advisability  of  obtaining  medical  advice  as  soon  as 
possible  is  seldom  so  forcU)ly  illustrated  as  in  case  of  in- 
fectious wounds.  The  earlier  treatment  is  begun,  the 
better  are  the  chances  for  a  favorable  course  and  recovery 
of  functional  power. 

Wounds  may  be  caused  by  the  action  of  caustics — by 
strong  solutions  of  carbolic  acid  for  example  ;  they  may 
become  inflamed  from  the  use  of  such  antiseptics  as  lysol, 
creolin,  and  iodoform.  Poisoned  wounds  may,  moreover, 
be  caused  by  the  bites  of  leeches,  snakes,  or  mad  dogs. 

A  review  of  the  methods  of  treatment  of  wounds 
belongs  to  the  realm  of  surgery.  One  point  will  bear 
emphasis  here,  however, — namely,  the  necessity  of  paying 
careful  attention  to  the  edges  of  the  wound,  with  the  view  to 
securing  as  slight  a  scar  as  possible.  The  vital  impor- 
tance of  treating  wounds  on  aseptic  principles  and,  if  nec- 
essary, antiseptically,  is,  of  course,  recognized  by  all  who 
are  in  accord  with  modern  scientific  teaching.  It  must  be 
added  that  aseptic  methods,  however  desirable  in  them- 
selves, are  not  adapted  for  home  treatment,  since  the  con- 
ditions necessary  to  their  success  are  to  be  found  only  in 
a  hospital. 

Every  wound  leaves  a  cicatrix,  the  size  of  which  varies 
with  the  amount  of  tissue  lost.  Wounds  that  heal  by 
first  intention  may  leave  such  small  cicatrices  that  they 
are  hardly  discernible  later  on,  and  may  disappear  alto- 
gether. A  cicatrix  may  be  but  the  depth  of  the  skin, 
or  it  may  extend  into  the  tissues  underneath  (cicatrix 
atrophica),  or  protrude  above  the  skin  (cicatrix  hyper- 
trophica).  It  may  be  movable  with  the  skin  or  be  at- 
tached to  the  underlying  structures,  even  to  the  bone  itself. 
Newly  formed  cicatrices  are  more  or  less  red  in  color,  but 
in  time  they  grow  paler  than  the  surrounding  tissue. 
While  they  are  often  very  sensitive  at  first,  old  cicatrices, 
especially  if  extensive,  are  generally  below  the  normal  in 
sensibility.  They  may,  on  the  other  hand,  be  exceedingly 
hyperesthetic  and  subject  to    neuralgic  pains.     In    such 


WOUNDS  OF  THE  SKIN.  43 

cases  a  slight  touch  sometimes  reflexly  calls  forth  pow- 
erful clouic  contractious,  which  are  undoubtedly  due  to 
irritation  of  nerve-fibers  caught  in  the  scar  during  healing. 
The  appearance  of  a  cicatrix  and  its  influence  on  the 
functional  activity  of  the  part  depend  upon  its  situation. 
Cicatrices  on  the  legs  remain  hyperemic  longer  than  when 
situat(Ml  on  the  trunk,  and  are  often  pigmented  in  addi- 
tion. In  some  individuals  hypertrophic  cicatrices  develop 
into  peculiar  nodular  growths  called  scar-keloids,  Avhich 
frequently  grow  rapidly,  and  are  apt  to  return  after  re- 
moval. (See  Plate  21.)  All  cicatrices  have  a  tendency 
toward  retraction  ;  this  is  most  marked  in  cases  of  deep 
and  extensive  burns.  The  cicatrix,  by  pulling  the  skin 
from  all  sides,  gives  it  a  ray-like  appearance.  If  the 
cicatrix  passes  over  a  joint,  motion  in  the  latter  is  im- 
peded, especially  in  cases  of  deeply  attached  scars  or  scar- 
keloids.  The  joint  may,  as  a  result,  become  completely 
ankylosed,  and  be  set  at  an  angle.  Cicatricial  tissue  over- 
lying a  joint  is  likely  to  be  overstretched  by  unguarded 
movements,  and  in  consequence  to  crack  and  become  sore. 
It  also  displays  great  sensitiveness  to  cold  in  this  situation. 
Much  suffering  may  arise  from  involvement  of  nerve- 
branches  in  the  scar,  while  similar  pressure  on  the  vessels 
interferes  with  the  circulation. 

Therapeutic  measures  are  calculated  only  to  neutralize 
or  diminish  the  harmful  effects  of  cicatrices.  The  latter 
may  be  prevented  from  cracking  by  inunction  with  some 
pure  fat,  l)y  the  use  of  a  suital)le  protective  bandage,  and, 
more  particularly,  by  limiting  the  movement  of  the  joint. 
In  case  of  impaired  mobility  of  a  joint  the  difficulty  can 
be  gradually  overcome  by  massage  and  systematic  exer- 
cise on  a  medicomechanical  apparatus,  with  a  view  to 
stretching  the  cicatrix.  If  the  attachments  of  the  cicatrix 
are  not  too  broad  and  deep,  it  may  gradually  be  loosened 
by  means  of  massage,  leading  in  favorable  cases  to  a 
regeneration  of  the  connective  tissue  of  the  whole  scar, 
which  is  very  deficient  in  fat  and  in  connectiv^e-tissue  cells. 


44  DISEASES  CAUSED  BY  ACCIDENTS. 

Electricity  is  also  of  service,  especially  in  the  induction 
of  hyperemia  by  direct  application  of  the  galvanic  cur- 
rent. Operative  interference  is  indicated  when  severe 
pain  is  caused  by  pressure  on  the  nerves  in  the  scar. 
Plastic  operations  are  often  advisable,  but  the  eifect  of 
the  new  scar  on  the  action  of  the  part  should  always  be 
carefully  considered  before  undertaking  any  operation  on 
cicatrices,  as  it  may  prove  more  disadvantageous  than  the 
offending  scar  itself.  Cicatrices  which  at  first  are  bound 
down  to  the  underlying  tissues  are  not  infrequently  loos- 
ened in  the  course  of  time,  as  a  result  of  the  unaided 
efforts  of  nature. 

The  treatment  of  hi(r)is  is  too  well  understood  to  need 
discussion  here.  Of  the  cicatrices  caused  by  burns  only 
those  produced  by  burns  of  the  third  degree  call  for 
mention  here.  Cicatrices  due  to  burns  of  the  second 
degree  are  usually  quite  superficial  and  movable,  and 
they  do  not  at  all  interfere  with  the  functional  activity  of 
the  part.  Burns  of  the  third  degree,  on  the  other  hand, 
often  leave  scars  that  are  hard  and  resistant  to  the  touch, 
firmly  bound  down,  and  quite  immovable.  Such  scars 
greatly  im])ede  the  circulation,  and  when  situated  around 
the  joints,  interfere  with  their  action  even  to  the  extent  of 
causing  complete  ankylosis.  This  is  most  freciuently  the 
case  when  the  wrist  or  ankle  is  involved.  The  cicatrices 
are  often  distinguished  by  a  marked  and  persistent  hyper- 
esthesia.      The  treatment  is  that  of  cicatrices  in  general. 

Abrasions  and  similar  trivial  injuries  of  a  leg  affected 
with  varicose  veins  deserve  brief  mention.  As  a  rule, 
such  injuries  receive  no  attention  until  ulceration  takes 
place,  either  for  the  first  time  or  at  the  site  of  a  former 
ulcer.  If  possible,  varicose  ulcers  should  be  treated  by 
zinc  salve  bandages,  and  the  patient  be  allowed  to  work. 
The  bandages  should,  at  any  rate,  be  given  a  trial  in  all 
appropriate  cases.  It  is  advisable  at  the  same  time  to 
])rohibit  the  ]iatient  from  doing  heavy  work  that  necessi- 
tates  his   standing,   or   from   carrying   heavy  loads.      lu 


WOUXDS  OF  THE  SKIN.  45 

severe  cases  rest  in  bed  is  indicated,  and  preferably  lios- 
pital  treatment. 

Frod-biffs  do  not  call  for  special  discussion  here.  The 
cicatrices  which  result  in  severe  cases  are  to  be  treated  as 
usual. 

The  ehanr/cs  in  the  shin  caused  by  gangrene  are  to  be 
judged  from  the  same  standpoint  as  burns,  frost-bites, 
and  their  scars. 

Anemia  of  the  skin  of  the  face  and  whole  body,  not  to 
be  confounded  with  the  peculiar  pallor  normal  to  some 
individuals,  is  often  seen  in  patients  who  have  passed 
through  a  serious  illness,  or  have  been  confined  to  a  sick- 
room for  a  long  time.  Local  anemia  occurs  very  fre- 
quently as  a  symptom  of  atrophy.  The  anemia  is  often 
preceded  for  a  considerable  period  by  a  hyperemia,  espe- 
cially in  case  of  impeded  circulation  of  the  lower  exr 
tremities  following  crushing  or  fracture.  The  condition 
is  distinguished  by  bluish-red  swellings  (hyperemias  of 
congestion).  The  temperature  of  the  part  may  be  raised 
or  distinctly  lowered.  Profuse  perspiration  occurs  in 
some  cases.  The  lividity  of  the  skin  may  even  amount 
to  complete  cyanosis. 

Therapeutically,  great  benefit  can  be  derived  from  warm 
baths,  either  local  or  general,  steam  baths,  massage,  med- 
icomechanical  exercises,  and  electricity.  When  the  dis- 
turbances previouslv  mentioned  are  consequent  upon  a  frac- 
ture, they  usually  begin  to  diminish  as  soon  as  complete 
union  is  established. 

Cicatrices  and  trophoneuroses  always  cause  an  atrophy 
of  the  skin.  It  grows  thin  and  dry,  poor  in  cells,  fat, 
and  blood-vessels,  and  tends  to  crack  and  to  form  gan- 
grenous ulcers,  especially  on  exposure  to  cold.  After 
nerve-injuries  it  is  cyanotic  and  cold  to  the  touch  (glossy 
skin).  The  patient,  too,  generally  complains  of  feeling 
cold  and  often,  even  in  summer,  wears  a  flannel  bandage 
or  a  warm  glove  around  the  part. 

The   chief  object  of  treatment   is  the  removal  of  the 


46  DISEASES  CAUSED  BY  ACCIDENTS. 

cause.  This  may,  however,  be  precluded  by  the  nature  of 
the  injury,  and  in  such  cases  temporary  relief  is  all  that 
can  be  hoj)ed  for. 

We  are  sometimes  called  upon  to  decide  whether  ele- 
2)hantiasis  of  the  lower  extremities  is  a  result  of  traumat- 
ism. This  disturbance  will  be  dealt  with  in  the  second 
part  of  the  book. 

Erysipdus  is  an  infectious  disease  of  the  skin  w'hich 
may  indirectly  be  due  to  traumatism,  since  a  very  insig- 
nificant wound  can  afford  entrance  to  the  germs  of  the 
disease.  It  often  causes  severe  general  disturbances,  for 
which  the  accident  is  also  to  beheld  indirectly  responsible. 

Tuberctdosk  of  the  skin  may  also  be  caused  by  trau- 
matism, indirectly  if  not  directly.  Direct  infection  occurs 
when  the  tubercle  bacilli  enter  the  body  through  a 
wound.  Thiem  mentions  four  forms  of  this  disease  fol- 
lowing injuries  :  (1)  The  ulcerative  form  ;  (2)  the  warty 
form,  affecting  the  external  layer  of  the  skin;  (3)  lupus; 
(4)  scrofuloderma. 

2.     INJURIES  AND  TRAUMATIC  DISEASES  OF  THE  NAILS. 

Crushing  of  the  distal  phalanx,  with  or  without  frac- 
ture, is  followed  l)y  an  inflammation  of  the  nail-bed,  often 
purulent  in  character,  as  a  result  of  which  the  nail  is  cast 
off.  The  new  nail  is  usually  misshapen,  and  sometimes  so 
atrophic  that  it  is  no  harder  than  the  horny  layer  of  the 
skin,  and  merges  into  the  latter  at  the  base  and  sides. 
Irregular  hypertrophic  processes  sometimes  develop  in 
the  middle  of  sucli  a  nail,  and  grow  quite  rapidly,  neces- 
sitating constant  trinuning,  especially  if  one  of  the  toe- 
nails is  involved.  In  the  latter  case,  without  such  trim- 
ming the  wearing  of  a  boot  is  impossible. 

Atrophy  of  the  nail  may  also  follow  an  injury  to  the 
nerves  supplying  the  distal  ])halanges  of  the  fingers  and 
toes. 

Other  disturl)ances  caused  by  injuries  to  the  nail  will  be 
discussed  in  Part  II  of  this  book. 


MUSCLES  AND  TENDONS.  47 


3.  INJURIES  AND  TRAUMATIC   DISEASES  OF  MUSCLES 
AND  TENDONS. 

Contusions  of  muscles  due  to  blows,  falls,  or  kicks 
usually  heal  quickly,  without  serious  sequels.  Blood 
extravasations  are  soon  absorbed,  especially  when  massage 
is  employed.  If  a  myositis  develops,  wet  compresses  at 
first  (Priessnitz),  with  weak  galvanism  and  like  measures 
later  on,  will  be  found  helpful. 

Sometimes  the  nerve  sup]>lying  the  muscle  is  injured  as 
well,  and  neuritis  or  paralysis  develops  in  consequence. 

In  cases  of  severe  crushing,  both  muscle-substance  and 
skin  are  apt  to  be  badly  toru,  and,  as  foreign  bodies  are 
frequently  carried  into  the  tissues,  purulent  inflammation 
often  follows.  A^'hen  healing  finally  takes  place,  the 
muscle  is  left  shrunken  and  partly  replaced  by  cicatricial 
tissue  which  causes,  in  time,  a  contraction  of  the  muscle 
and  in  certain  cases  a  contracture  of  tlie  whole  limb. 
Massage,  local  steam  baths,  and  medicomechanical  exer- 
cises will  act  favorably  on  the  cicatrices  and  the  disturb- 
ances to  which  they  give  rise,  even  though  a  complete 
cure  can  not  l)e  effected.  In  some  cases,  however,  all 
treatment  fails  to  relieve  the  condition. 

The  complications  which  we  need  to  consider  are  lacer- 
ations of  the  skin  and  other  soft  parts  and  fractures  of  tlie 
bones.  The  muscles  may  be  lacerated  or  pierced  by  frac- 
tured bones.  A  discussion,  however,  of  these  injuries 
will  not  be  entered  upon  at  this  time.  When  the  skin  is 
also  pierced,  a  hernia  of  the  muscle  may  result,  but  this 
may  cause  no  functional  disturl^ancc.  Partial  lacerations 
due  to  falls,  kicks,  and  similar  accidents  can  not  be  dis- 
tinguished from  the  contusions  and  crushings  already  men- 
tioned— the  diagnosis  of  muscle-laceration  often  serves  for 
either  of  the  other  conditions. 

The  phrase  "  muscle  strain  "  denotes  slight  lacerations 
of  the  muscle-substance  caused  l)y  indirect  violence.  The 
injury  may  be  looked  upon  as   an   early  stage  of  serious 


48  DISEASES  CAUSED  BY  ACCIDENTS. 

subcutaneous  ruptures.  The  latter  are  most  frequently- 
seated  in  the  biceps  of  the  arm,  but  may  occur  also  in  the 
muscles  of  the  calf,  the  upper  part  of  the  thigh,  and  the 
abdomen.  The  injury  is  caused  by  the  forced  contraction 
of  a  muscle  while  the  limb  is  in  violent  motion,  as  in 
parrying  blows,  for  instance.  In  consequence  of  the 
retraction  of  the  torn  ends  of  the  muscle  quite  a  broad  gap 
may  be  left  between  them,  and  often  remains  as  a  perma- 
nent defect,  unless  the  muscle  is  repaired  by  operation. 
Tlie  degree  of  atrophy  of  the  muscle  and  the  loss  of  power 
depend  upon  the  extent  of  the  injury.  The  point  of  rup- 
ture can  most  readily  be  distinguished  when  the  muscle  is 
contracted  or  put  on  the  stretch.  During  contraction  it 
appears  as  a  ball-like  mass,  especially  n<jticeable  in  the 
case  of  the  biceps  of  the  arm.  Ruptures  usually  involve 
only  a  part  of  the  muscles,  complete  ruptures  being  very 
rarely  observed.  The  muscle  proper  is  not  always  con- 
cerned in  the  injury  :  sometimes  it  is  the  tendon  that  is 
ruptured,  or  a  bit  of  bone  is  torn  off  at  the  point  of  attach- 
ment ;  occasionally,  the  muscle  or  tendon  sutlers  partial 
rupture  at  the  same  time. 

The  inflammations  that  attack  muscles  after  crushing 
have  already  been  referred  to.  Even  slight  injuries  often 
give  rise  to  severe  suppurative  processes,  necessitating  re- 
peated operations,  as  a  result  of  which  an  extensive  growth 
of  cicatricial  tissue  takes  place  with  the  usual  sequels  of 
atrophy  and  disturbances  of  temperature  and  circulation. 
Complete  loss  of  function  is  the  rule  in  such  cases.  Par- 
alysis of  muscles  is  equivalent  to  paralysis  of  the  motor 
nerves  that  supply  them. 

The  paralysis  may  be  complete  or  only  partial,  and 
upon  this  point  depends  the  degree  to  which  tlie  muscle  is 
functionally  disabled.  A  paralyzed  muscle  loses  its  tone, 
and  soon  undergoes  atrophy,  whicih  in  some  cases  becomes 
extreme.  In  cases  of  jiartial  paralysis  the  electric  irrita- 
biHty  is  diminished,  and  in  cases  of  complete  paralysis  it 
is  entirely  lost  (partial  or  complete  reaction  of  degenera- 


MUSCULAR   ATROPHY.  49 

tion).  Large  muscles  may  be  wholly  or  only  in  part  affected 
by  the  paralysis. 

Muscles  frequently  suifer  dislocation  in  consequence  of 
the  rotation  of  the  ends  of  fractured  bones  or  of  the  dis- 
location of  certain  joints.  The  subject  will  be  considered 
in  the  second  part  of  this  book. 

Muscular  Atrophy. 

A  muscle  is  an  apparatus  of  movement,  having  the 
function  of  imparting  a  certain  limited  motion  to  that  part 
of  the  skeleton  to  which  it  is  attached.  The  motion  is 
caused  by  the  contraction  of  the  muscle,  and  such  contrac- 
tions are  necessary  to  its  good  condition.  By  regular  exer- 
cise a  muscle  is  made  larger  and  firmer,  as  evidenced  by 
acrobats,  gymnasts,  oarsmen,  etc.  Disuse  has  the  reverse 
effect :  the  muscle  loses  in  size  and  strength,  and  becomes 
soft  and  flabby.  This  condition  is  known  as  atrophy,  or 
the  atrophy  of  disuse.  The  opposite  condition, — an  ab- 
normal increase  in  size, — arising  from  constant  training,  is 
termed  hypertrophy. 

The  fibers  of  an  atrophic  muscle  are  in  a  state  of  de- 
greneration,  the  nuclei  beino;  increased  in  number. 

Atrophy  is  to  be  distinguished  from  atony  ;  the  latter 
denotes  a  condition  of  temporary  or  permanent  relaxation. 
While  an  atrophic  muscle  is  necessarily  also  in  a  state  of 
atony,  the  reverse  does  not  hold  good.  Although  atony  is 
often  a  precursor  of  atrophy,  it  may  be  only  a  sign  of 
temporary  fatigue  on  the  part  of  a  healthy  muscle.  The 
expression  "  atrophy  of  disuse  "  is  not  altogether  applic- 
able to  the  condition  previously  described  ;  it  is,  indeed, 
often  inai)propriately  used.  The  atrophy  of  disuse,  as  com- 
monly understood,  expresses  a  wasting  of  the  muscle  con- 
sequent upon  inactivity  ;  the  functional  power  is  not  lost. 
It  is  observed,  for  instance,  in  muscles  kept  inactive  be- 
cause of  pain  consequent  upon  motion  of  an  inflamed  joint. 
If,  on  the  other  hand,  a  muscle  loses  its  functional  j^ower, 
.  as  in  cases  of  fracture  or  paralysis,  the  atrophy  which  it 
4 


50  DISEASES   CAUSED  BY  ACCIDENTS. 

then  undergoes,  although  the  consequence  of  inactivity, 
differs  to  a  marked  degree  from  that  of  the  other  form. 
It  is,  perhaps,  permissible  to  speak  of  the  two  forms  in  the 
order  described  as  the  atrophy  of  voluntary  and  involun- 
tary disuse,  respectively.  The  prognosis  differs  consider- 
ably for  the  two  forms. 

Muscular  atrophy  can  be  divided  into  three  forms,  with 
reference  to  its  origin  :  (1)  Myogenous  ;  (2)  neurogenous  ; 
(3)  infectious.  (Firgau,  "Arch.  f.  Unfhkd.,"  vol.  ii,  books 
2  and  3.) 

In  the  first  form  the  process  begins  in  the  muscle  itself. 
As  a  result  of  a  fracture  of  a  bone  to  which  the  muscle  is 
attached,  its  point  of  origin  and  of  insertion  approach  each 
other  ;  the  muscle  loses  its  tone,  and  subsequently  atrophies. 
Atrophies  consequent  upon  diseases  of  the  joints  are  also 
included  in  this  group. 

The  neurogenous  form  comprises  the  atrophies  due  to 
injuries  and  inflammation  of  the  nerve.  When  the  nerve 
undergoes  degeneration,  the  atrophy  is  of  the  degenerative 
type. 

The  third  form  includes  the  atrophies  that  follow  an  in- 
fectious process,  such  as  a  suppurative  inflammation. 

Muscular  atrophy,  as  a  rule,  affects  only  part  of  the 
muscle,  complete  atrophy  being  very  rarely  observed. 

In  respect  to  prognosis  nuiscular  atrophies  are  to  be 
divided  into  curable  and  incurable. 

We  must  bear  in  mind,  too,  that  local  paralyses  and 
atrophies  may  be  caused  by  systemic  poisoning — as,  for 
instance,  by  lead,  arsenic,  or  alcohol.  This  adds  a  fourth 
form,  of  toxic  origin. 

The  diagnosis  of  muscular  atro])hy  is  usually  simple. 

In  making  an  examination  the  affected  part  should 
always  be  compared  with  that  of  the  opposite  side,  both 
at  rest  and  during  contraction.  Changes  in  size  and  shape 
of  the  nuiscle  and  in  the  position  of  anatomic  landmarks 
are  thus  clearly  brought  out.  In  the  case  of  the  lower 
extremities  the  landmarks  will  invariably  be  found  lower 


I 


MUSCULAR   ATROPHY.  51 

down  on  the  atrophied  e;ide.  To  the  touch,  an  atrophied 
muscle  feels  s(jft  and  flabby.  The  electric  excitability 
may  be  normal,  diminished,  or  completely  lost.  The  skin 
over  the  affected  nuiscle  is  fixniuently  cold,  especially  in 
cases  of  paralysis,  and  may  a])pear  dark  red  or  cyanotic. 
Functional  power  is,  as  a  rule,  diminished  most  appreci- 
ably as  to  strength  and  endurance  ;  we  do,  however,  occa- 
sionally see  marked  cases  of  atrophy  without  ap})arent 
loss  of  power.  [Fibrillary  twitchings  are  very  frequently 
present  in  atrophying  muscle. — Ed.] 

The  atrophic  process  is  seldom  confined  to  one  muscle, 
but  extends,  as  a  rule,  over  the  whole  limb.  Thus,  atrophy 
of  the  extensor  muscles  is  followed  by  atrophy  of  the 
flexors,  but  the  primary  process  is  usually  better  marked 
than  the  secondary.  The  atrophy  may  vary  in  degree 
even  in  different  parts  of  the  same  muscle,  as  often 
observed  in  the  deltoid,  liiceps,  etc. 

The  prognosis  of  muscular  atrophy  depends,  first  of 
all,  on  the  nature  of  its  cause. 

The  form  to  which  reference  has  been  made  as  the 
atrophy  of  "  voluntary  "  disuse  can  be  cured  with  relative 
ease.  Massage,  electricity,  and  medicomechanical  gym- 
nastics will  restore  the  muscles  to  their  former  condition 
within  a  few  weeks. 

Paralyzed  muscles  require  a  much  longer  course  of 
treatment,  but  are  also  entirely  curable  unless  the  paralysis 
depends  on  the  division  of  a  nerve,  in  wdiich  case  it  is 
permanent. 

An  absolutely  unfavoral)lc  prognosis  must  also  be  made 
after  extensive  suppuration,  when  the  joint  is  permanently 
stiffened,  or  when  the  tendon  is  torn  from  the  bone  at  its 
point  of  insertion,  as  frequently  occurs  in  cases  of  frac- 
ture of  the  patella  or  the  olecranon  process.  When  a 
limb  is  shortened  by  fracture,  the  atrophied  muscles  do 
not  regain  their  original  size  and  strength,  but  adapt  them- 
selves in  these  respects  to  their  new  requirements. 

In  regard  to  the  question  of  treatment  we  must,  first 


52  DISEASES  CAUSED  BY  ACCIDENTS. 

of  all,  carefully  consider  the  cause  of  the  atrophy  and  the 
possibility  of  its  removal.  We  will  then  be  readily  able 
to  judge  ^vhat,  if  any,  are  the  chances  for  improvement. 
If  the  outlook  is  favorable,  benefit  will  certainly  be  de- 
rived from  massage,  baths,  c!old  douches,  electricity,  and 
medicomechanical  gymnastics. 

4.  INJURIES  AND  TRAUMATIC  DISORDERS  OF  TENDONS 
AND  TENDON=SHEATHS. 

The  superficial  location  of  most  of  the  tendons  renders 
them  very  liable  to  injury.  Contusions  and,  more  espe- 
cially, the  crushing  of  a  tendon  very  frequently  lead  to 
an  acute  tenosynovitis,  which  is  exceedingly  painful,  but 
which,  if  treated  at  once  by  rest  and  compresses,  may 
soon  be  allayed.  If  suppuration  sets  in,  liowever,  the 
process  is  greatly  prolonged,  and  the  prognosis  as  to 
restoration  of  function  becomes  unfavorable,  especially  if 
shreds  of  the  tendon  slough  off.  The  removal  of  a  piece 
of  tendon  entails  permanent  loss  of  functional  power. 
Acute  tenosynovitis  occurs  also  as  a  result  of  strain. 
Chronic  tenosynovitis  is  recognizable  by  crepitus  on 
movement ;  it  is  not,  as  a  rule,  painful,  l)ut  leads  to  con- 
tractures which,  in  turn,  cause  functional  disability,  as 
when  the  hand,  for  instance,  is  involved.  It  is  important 
to  remember  that  a  tendon  affected  by  chronic  inflamma- 
tion has  lost  its  elasticity,  and  is  therefore  liable  to  be 
ruptured  by  a  strain.  Worl^men  who  constantly  use  their 
hands  in  firmly  grasping  and  holding  an  object  often  suf- 
fer from  chronic  tenosynovitis  of  the  fingers,  with  conse- 
quent contractures  of  the  latter.  The  chronic  inflamma- 
tion develops  as  the  sequel  of  an  acute  process  caused  by 
repeated  strains.  The  assocnated  muscles  are  always  more 
or  less  atrophied  in  these  chronic  cases. 

Incised  Avounds  that  completely  sever  the  tendon  are 
of  frequent  occurrence  among  certain  classes  of  work- 
men, such  as  wood-carvers,  ('ar[)enters,  and  others  who 
use  circular   saws   and  similar  machines.     Glaziers  and 


THE  BURS^.  53 

slate-roofers  suffer  this  injury  by  flilling  on  glass  or  slate 
with  the  forearm  outstretched. 

Unless  the  tendon  is  sutured,  its  functional  power  is 
permanently  lost.  If  several  tendons,  those  of  the  fore- 
arm, for  instance,  are  severed,  it  is  difficult  to  suture 
them  in  the  proper  order,  and  a  mistake  leads  to  decided 
functional  disturbance. 

Subcutaneous  ruptures,  which  have  been  referred  to  in 
the  chapter  on  muscles,  are  more  apt  to  involve  diseased 
than  healthy  tendons.  When  rupture  occurs,  or  when  in 
addition  to  rupture  the  bone  is  fractured  at  the  point  of 
insertion  of  the  tendon,  the  muscle  at  once  relaxes,  and, 
imless  its  tone  is  restored  by  operation,  it  undergoes 
atrophy.  Later  on,  when  the  atrophy  has  become  well 
established,  it  is  too  late  to  expect  benefit  from  any  form 
of  treatment. 

Tendons  may  become  displaced,  most  frequently  those 
of  the  long  head  of  the  biceps,  the  peroneus  longus,  and 
the  tibialis  anticus.  When  the  accident  causes  much  in- 
convenience, it  is  advisable  to  fasten  the  tendon  in  its  nor- 
mal position — a  procedure  that  gives  excellent  results. 
Complete  displacement  of  a  tendon  deprives  it,  of  course, 
of  all  functional  power. 

Tendons  are  often  dislocated  simultaneously  witli  their 
muscles  when  their  normal  relations  are  disturbed  as  a 
result  of  ill-set  fractures  or  stiffness  of  a  joint.  Such  dis- 
locations impede  the  action  of  the  joint  with  which  they 
are  associated. 

5.  INJURIES  AND  TRAUMATIC  DISEASES  OF  BURS/E. 

Bursitis  is  very  frequently  seen  in  accident-practice  as 
a  consequence  of  crushing.  When  the  large  bursa  of  the 
knee  is  affected,  the  diagnosis  is  very  plain,  but  the  con- 
dition is  not  so  easily  recognized  in  other  locations — as, 
for  instance,  on  the  shoulder,  hip,  hand,  or  foot.  Unless 
the  bursse  communicating  with  the  joints  are  involved, 
there   is   no    pain,  even    during  the   acute   inflammatory 


54  DISEASES  CAUSED  BY  ACCIDENTS. 

stage,  and  tlie  patients  usually  are  able  to  perform  their 
customary  duties  without  inconvenience.  When  the  exu- 
dation is  absorbed,  the  membrane  remains  thickened  and 
dry ;  crepitus  then  becomes  noticeable,  and  is  sometimes 
so  loud  as  to  be  heard  at  a  considerable  distance.  The 
usefulness  of  the  bursa  is  not  thereby  impaired,  however. 
A  muscle  whose  tendon  })lays  over  a  large  bursa  undergoes 
atrophy  during  an  acute  inflammation  of  the  latter,  and 
does  not  completely  recover  for  some  time  after  the  subsid- 
ence of  the  disease.  It  is  a  well-known  fact  that  bursi- 
tis is  very  likely  to  become  recurrent. 

The  atfection  is  frequently  observed  as  the  result  of 
constant  irritation  of  certain  parts — as,  for  instance,  the 
shoulder  in  porters,  and  the  knee  in  scrub-women.  Such 
irritation  sometimes  causes  the  formation  of  new  bursae. 

Bursse  occasionally  become  displaced.  I  shall  refer  in 
the  second  part  of  the  book  to  a  case  of  this  kind  involv- 
ing the  subcalcanean  bursa. 

6.  INJURIES  AND  DISEASES  OF  FASCI/E. 

When  the  fascia  investing  a  muscle  is  torn,  the  latter 
presses  through  the  opening  and  forms  a  muscle  hernia. 
The  injury  may  be  directly  caused  by  crushing  or  l)y 
penetration  of  the  sharp  ends  of  a  fractured  bone,  or  it 
may  be  due  to  indirect  violence.  We  see  illustrations  of 
the  latter  mode  of  origin  in  hernias  of  the  thigh-nuiscles 
in  riders,  especially  cavalrymen,  and  in  those  of  the  calf- 
muscles  in  athletes  who  practise  jumping.  The  hernias 
appear  as  small,  soft  tumors,  giving  rise  to  no  inconveni- 
ence, and  never,  in  my  experience,  to  permanent  dis- 
ability. They  are  quite  often  seen  in  workmen,  generally 
in  the  lower  extremities,  and  it  is  often  difficult  to  ascer- 
tain how  they  were  caused. 

Contracture  of  the  palmar  fascia,  with  consequent  con- 
tracture of  the  fingers,  follows  repeated  strains,  suppura- 
tive inflammations,  or  traumatism  of  any  kind  that  gives 
rise  to  trophic  disturbances.     The  injury  may  be  local, 


THE  LIGAMENTS  AND  CAPSULES.  55 

such  as  crushing  of  the  pahii  of  the  hand  with  subsequent 
neuritis,  or  may  affect  the  spinal  cord,  causing  degenera- 
tion of  the  ganglion  cells  of  the  anterior  horns. 

The  plantar  fascia  likewise  may  become  irregularly 
thickened  and  contracted  as  the  result  of  direct  trauma- 
tism, or  of  injury  to  related  structures — as,  for  instance, 
fracture  of  the  os  calcis.  It  is  to  be  noted  that  the  toes 
are  not  involved  in  the  contractures  ;  the  knot-like  points 
of  thickening  of  the  fascia,  however,  interfere  with 
walking. 

7.  INJURIES  AND  TRAUMATIC  DISORDERS  OF  LIQA= 
MENTS  AND  CAPSULES. 

Torsion  may  cause  the  laceration  of  the  ligaments  and 
capsules  of  a  joint,  but,  as  a  rule,  the  injury  is  too  slight 
to  result  in  permanent  trouble.  The  ligaments  may,  on 
the  other  hand,  be  so  badly  torn  as  to  lead  to  loose-jointed- 
ness,  as  is  frequently  observed  in  the  case  of  the  knee- 
joint.  The  lacerations  caused  by  dislocations  are  much 
more  extensive,  and  are  apt,  in  spite  of  the  most  skilful 
treatment,  to  lead  to  contracture  and  ankylosis. 

Other  traumatic  diseases  of  these  structures  to  be  men- 
tioned are  the  following :  Thickening  of  the  capsule,  with 
hyperplasia  of  the  synovial  folds  following  inflannnatory 
exudation;  relaxation  of  capsule  and  ligaments,  with  con- 
sequent loose-jointedness,  seen  in  cases  of  paralysis;  cica- 
tricial contractures  after  lacerations,  etc. 

8.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
BLOOD= VESSELS. 

The  radial  and  ulnar  arteries  are  those  most  frequently 
involved  in  direct  traumatism,  since  the  forearm  is  par- 
ticularly exposed  to  the  danger  of  blows  and  incised 
wounds. 

Lacerations  of  arteries  caused  by  fracture  and  severe 
crushing  are  a  more  serious  form  of  injury,  especially 
in   cases  when  the  lower  extremities  are  involved.     The 


6  6  DISEA  SES  CA  USED  ST  A  CC I  DENTS. 

blood  extravasations  and  venous  stasis  are  very  extensive, 
and  the  edema  and  cyanosis  which  follow  persist  for  a  long 
time. 

Aneurysms  develop  either  as  a  result  of  direct  violence 
to  the  arteries  or  of  strain.  By  careful  inquiry,  we  can 
generally  ascertain  the  true  cause  of  the  injury.  A 
patient  is  always  more  or  less  disabled  by  an  aneurysm, 
the  degree  to  which  his  working  capacity  is  curtailed 
depending  on  the  size  and  location  of  the  aneurysm.  In 
many  cases  he  is  incapable  of  self-support.  Heavy  work 
is  always  to  be  prohibited. 

Arteriosclerosis  is  a  disease  to  which  workmen  are 
especially  subject.  It  can  usually  be  traced  to  the  eifects 
of  alcoholism,  syphilis,  chronic  lead-poisoning,  gout,  and 
the  deprivations  of  poverty.  It  may,  however,  develop 
as  the  result  of  an  accident,  or  its  development  may  be 
hastened  thereby.  It  is  then  usually  to  be  looked  upon 
as  a  symptom  of  an  advanced  stage  of  accident-neurosis, 
of  which  tachycardia  is  an  early  symptom.  In  such  cases 
it  has  a  good  psychic  effect  on  tlie  patient  to  make  the 
examination  and  settle  the  question  of  insurance  as  soon 
as  possible.  In  addition,  all  excitement  is  to  be  avoided. 
Many  cases  thus  treated  show  decided  improvement  in 
time. 

In  arteriosclerosis  there  is  constant  danger  of  rupture 
of  the  vessel-walls,  which  are  inelastic  and  brittle ;  hence, 
the  patient  is  always  liable  to  an  attack  of  apoplexy. 
When  the  arteriosclerosis  is,  directly  or  indirectly,  caused 
by  an  accident,  the  apoplexy  that  results  is  also,  in  the 
eyes  of  the  law,  to  be  attril)uted  to  the  accident. 

Varicose  veins  are  frecpiently  seen  in  workmen  as  a 
result  of  prolonged  standing,  or  of  repeated  attacks  of  con- 
stipation. The  disease,  however,  may  be  hereditary. 
Unless  complicated  l)y  phlebitis,  eczema,  or  varicose  ulcers, 
the  varicosities  may  be  very  large  and  yet  not  interfere 
with  Avork.  The  affected  individual  may,  on  the  other 
hand,  suffer  great  inconvenience  and  be  seriously  crippled. 


THE  NERVES.  57 

It  is  a  well-known  fact  that  a  slight  abrasion  of  the  skin 
of  a  leg  thus  atfected,  especially  if  neglected,  is  very  apt 
to  lead  to  the  formation  of  an  nicer  which  is  exceedingly 
slow  to  heal  and  ever  ready  to  recur. 

Such  injuries  as  fractures  of  the  leg  or  thigh,  with 
marked  displacement  of  the  broken  bones,  the  growth  of 
larsfe  calluses  or  extensive  cicatrices  act  either  as  direct 
causes  for  the  development  of  varicose  veins,  or  increase 
a  preexisting  affection.  Shortening  of  a  limb  after  frac- 
ture may  also  have  the  latter  effect.  A  limb  which  is  the 
seat  of  varicose  veins  is  always  increased  in  size,  and  may 
be  so  highly  edematous  in  consequence  of  a  succession  of 
ulcers  or  thromboses  as  to  well  warrant  the  use  of  the 
term  elephantiasis  cruris. 

It  is  worthy  of  note  that  the  bone  in  cases  of  marked 
varicosity,  more  especially  when  complicated  with  recurrent 
ulcers,  is  often  greatly  thickened.  In  one  case  of  my  own, 
that  of  a  workman  about  thirty-seven  years  of  age,  the 
fibula  was  shown  by  an  X-ray  photograph  to  be  as  large 
as  the  tibia,  if  not  larger.  Such  hypertrophic  bones  are 
said  to  be  denser  than  normal. 

9.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
NERVES. 

Slight  contusions  of  the  nerves,  caused  by  falls,  kicks, 
or  blows,  usually  give  rise  to  only  temporary  disturbances 
of  sensation,  such  as  numbness  or  formication.  There 
may  also  be  paralysis,  which,  as  a  rule,  passes  off  in  a 
few  days ;  even  when  it  persists  for  a  long  time  after  a 
severe  injury,  it  can  usually  be  cured  eventually.  Some- 
times the  paralysis  is  accompanied  by  symptoms  of  neu- 
ritis, or  there  may  be  neuritis  without  paralysis.  For  the 
paralysis,  massage,  baths,  medicomechanical  gymnastics, 
and  electricity  are  to  be  recommended,  and  their  good 
effect  is  usually  soon  apparent.  When  the  muscles  have 
undergone  atrophy,  they  will  invariably  be  found  to  need 
treatment    for   some    time    after   the  paralysis  is    cured. 


58  DISEASES  CAUSED  BY  ACCIDENTS. 

Neuritis,  during;  the  period  of  greatest  pain,  is  best  treated 
by  a  weak  galvanic  current,  or  by  small  sparks  from  a 
static  machine. 

Dislocations  or  fractures  may  cause  stretching  of  a  nerve, 
and  as  a  result  it  is  frequently  strained  and  partially  torn. 
The  paralysis  or  neuritis  that  follows  such  injuries  is 
always  of  a  more  serious  nature  than  in  cases  of  simple 
contusion.  The  prognosis  is  a  more  favorable  one  when 
the  bones  or  joints  are  set  at  once.  When  a  nerve  is  in- 
volved in  the  growth  of  a  callus,  it  undergoes  pressure- 
atrophy  ;  the  muscles  which  it  supplies  atrophy  rapidly  in 
consequence,  and  trophoneurotic  disturbances  soon  become 
apparent.  The  only  hope  of  cure  lies  in  surgical  inter- 
ference, in  releasing  the  nerve  from  the  callus. 

Dislocations  of  nerves  have  so  flir  been  observed  only 
in  the  case  of  the  ulnar  at  the  elbow.  The  paralysis  that 
ensues  can  be  cured  by  replacing  the  nerve  and  suturing 
it  in  position.  The  complete  severance  of  a  nerve  by  a 
cut  or  similar  injury  is  necessarily  followed  by  paralysis 
and  trophoneurotic  disorders.  The  median  and  ulnar 
nerves  in  their  course  down  the  forearm  are  those  most 
frequently  involved,  because  most  exposed  to  accidents  of 
the  kind.  If  not  promptly  sutured,  the  nerve  will  de- 
generate, and  the  nuiscles  it  controls  will  be  completely 
paralyzed,  unless,  as  happens  in  rare  cases,  the  cut  ends 
do  not  retract  and  become  reunited  by  a  growth  of  ner<'e- 
callus. 

For  the  symptoms  of  trophoneurosis  I  would  refer  the 
reader  to  the  cases  and  illustrations  in  the  second  part  of 
this  book.  (Plate  XXII.)  The  peripheral  end  of  a 
severed  and  completely  paralyzed  nerve  when  stimulated 
by  the  galvanic  current  gives  the  reaction  of  degenera- 
tion. 

If  the  nerve  is  not  completely  severed,  or  if  union  has 
taken  place  by  the  formation  of  nerve-callus,  we  may  hope 
for  gradual  improvement  in  the  paralysis,  although  it  may 
not  become  apparent  for  a  year  or  two.     The  power  of 


NEURALGIA.  59 

voluntary  motion  may  be  regained  earlier  than  galvanic 
or  faraclic  excitability. 

Paralyses  through  nerve-affections  are  often  caused  by 
injuries,  a  number  of  which  have  already  been  mentioned. 

Neuralgia. 

By  this  term  is  meant  a  severe  attack  of  pain  in  one  or 
more  nerves,  in  which  no  definite  pathologic  changes  can 
be  recognized.  Neuralgia  has  a  multiplicity  of  causes ; 
we  are  here  specially  concerned  with  those  of  a  traumatic 
nature.  It  may  follow  direct  injury  to  the  nerve,  or  it 
may  be  due  to  some  pressure  on  the  nerve,  as  in  case  of 
callus,  aneuiysm,  etc.  The  pain  is  usually  confined  to 
one  nerve  and  its  branches,  which  can  be  clearly  traced 
by  the  tenderness  felt  on  pressure. 

Predisposition  to  neuralgia  is  an  important  factor  in  its 
development,  even  when  traumatism  is  the  exciting  cause. 
Chronic  alcoholism  and  chronic  lead-poisoning  are  among 
the  predisposing  causes.  In  such  cases  a  slight  injury  to 
the  hand  or  foot  may  give  rise  to  a  neuralgia  of  the  whole 
limb.  Accurately  speaking,  neuralgia  is  not  directly 
caused  by  traumatism,  but  develops,  as  already  indicated, 
in  consequence  of  a  predisposition  that  only  needs  special 
stimulation  in  order  to  assert  itself;  it  must  not  be  con- 
founded with  the  pain  due  to  the  injury  itself:  Neuralgia 
may  be  excited  also  by  neuromata  or  by  diseases  of  the 
periosteum  or  bone. 

In  treating  the  affection  we  must  consider  the  idio- 
syncrasy of  the  patient.  Some  individuals  are  much 
benefited  by  massage,  while  it  does  not  agree  at  all  with 
others.  Much  depends  on  the  skill  and  judgment  of  the 
operator.  Galvanism  should  always  be  tried,  at  first  using 
a  weak  current. 

The  electric  spark  of  the  static  machine  often  gives 
brilliant  results  ;  also  the  employment  of  the  static  breeze 
is  sometimes  useful. 

Hot  wet  compresses,  inunctions  of  chloroform,  oil  of 


GO  DISEASES  CAUSED  BY  ACCIDENTS. 

hyoscyamiis,  etc.,  are  sometimes  found  useful.  In  some 
severe  cases  that  had  resisted  all  previous  treatment  nerve- 
stretching  has  been  practised  with  success. 

The  internal  treatment  includes  the  use  of  quinin, 
arsenic,  salicylate  of  soda,  iodid  of  potassium,  antipyrin, 
phenacetin,  etc. 

Mild  forms  of  neuralgia,  although  causing  the  patient 
great  discomfort,  do  not  give  rise  to  fever  or  affect  the 
general  health.  Tiie  appearance  of  the  patient  so  little 
accords  with  his  sufferings  that  simulation  may  be  sus- 
pected. In  severe  cases  of  long  duration,  on  the  other 
hand,  the  general  health  deteriorates  very  considerably. 

It  is  hardly  necessary  to  mention  the  difficulty  that  fre- 
quently confronts  us  of  distinguishing  between  neuralgia 

and  neuritis. 

Neuritis. 

Neuritis  may  be  directly  or  indirectly  excited  by  trau- 
matism. 

Among  the  causes  frequently  observed  are  the  follow- 
ing :  Contusions,  dislocations  and  fractures,  incised  wounds 
of  all  kinds,  penetration  by  splinters  of  glass,  etc.,  cal- 
luses, exostoses,  or  frequently  repeated  pressure  from  any 
source.  Neuritis  may  develoji,  also,  as  a  result  of  inflam- 
mations in  neighboring  structures,  such  as  the  tendon- 
sheaths,  the  periosteum,  or  the  joints  ;  or  of  inflammations 
affecting  the  whole  limb  or  region.  It  is  especially  prone 
to  occur  in  consequence  of  phlegmonous  inflammations. 

In  respect  to  the  symptomatology  of  neuritis,  which  is 
too  well  known  to  need  repetition  here,  it  is  sufficient  to 
state  that  acute  neuritis  often  sets  in  with  high  fever,  and 
that  it  is  exceedingly  painful. 

The  patient  is  completely  disabled  during  an  acute 
attack,  and  may  be  partly  cripj^led  by  the  chronic  form. 

It  is  important  to  remember  that  an  ascending  neuritis, 
developing  after  a  peripheral  injury  and  progressing  up- 
ward along  the  course  of  the  nerve  to  the  nerve-centers, 
eventually  gives  rise  to  symptoms  that  ordinarily  indicate 


THE  BONES.  61 

disease  of  the  latter.      The  treatment   is  similar  to  that 
given  for  neuralgia. 

Alcoholic  neuritis  may  be  directly  excited  by  trauma- 
tism, or  may  be  thereby  increased  in  severity.  Crushing 
of  the  leg  or  knee  involving  the  peroneal  nerve,  crushing 
of  the  hand,  and  similar  injuries  in  alcoholic  subjects, 
may  cause  a  local  neuritis  (of  the  peroneal  nerve,  for 
instance)  or  a  multiple  neuritis.  Alcoholic  neuritis  is 
exceedingly  resistant  to  treatment,  and  varies  in  intensity 
and  symptoms  in  proportion  to  the  quantity  of  alcohol 
consumed.  The  symptoms  are  as  follows  :  Motor  par- 
alysis of  the  peroneal  muscles  and  the  quadriceps  extensor, 
while  the  patellar  reflex  is  either  lost  or  greatly  exagger- 
ated. [In  the  early  stage  of  multiple  neuritis  the  knee- 
jerk  is  sometimes  hypertvpical.  This  is  replaced,  as  the 
disease  progresses,  by  diminution  or  loss.  Greatly  exag- 
gerated knee-jerk  does  not  occur  in  uncomplicated  neuritis. 
— Ed.]  Eventually  there  are  paralysis  of  the  extensors 
of  the  forearm,  disturbances  of  sensation,  paresthesias, 
ataxia,  etc. 


10.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
BONES. 

Eemnrks  on  Structure,  Function,  and  Strength  of  Bones. — BOnes  vary 
in  stieni;th,  shape,  and  size  according  to  the  functions  that  tliey  per- 
form. Tiiey  are  able,  by  reason  of  their  structure,  to  withstand  strong 
pressure  as  well  as  traction.  The  adaptation  of  structure  to  function 
is  well  illustrated  by  the  arrangement  of  the  bony  fibers  alter 
fractures. 

A  bone  is  composed  of  two  varieties  of  substance — one,  hard  and 
compact ;  the  other,  spongy  and  somewhat  elastic.  In  the  long  bones 
the  compact  su])stance  preponderates  in  the  diaphy.sis,  while  the  epiph- 
yses are  composed  largely  of  spongy  bone,  which,  by  reason  of  its 
elasticity,  is  well  adapted  to  resist  exposure  to  pressure  and  strain. 

The  bones  vary  as  to  shape  and  elasticity  in  different  periods  of 
life.  The  epiphysis  is  not  ossitied,  on  the  average,  before  the  twen- 
tieth year.  To  the  elasticity  of  the  bones  in  childhood  is  due  the  fact 
that  fractures  occur  less  frequently,  and  that  they  heal  more  rapidly 
and  perfectly,  than  in  adult  life.  Investigations  have  been  made  by 
which  the  strengtli  and  elasticity  of  different  bones  at  different  ages, 
and  in  comparison  with  other  substances, — such   as   metids,  alloys, 


62  DISEASES   CAUSED  BY  ACCIDENTS. 

■wood,  and  stone, — have  been  definitely  determined.  Messerer  gives 
the  lollowing  figures  in  regard  to  tiie  power  of  resistance  to  pres- 
sure of  different  bones  :  Fracture  of  the  chivicle  was  caused  in  men 
by  an  average  weight  of  192  kilos;  in  women,  by  a  weight  of  126 
kilos.  In  one  woman  the  humerus  was  fractured  l)y  a  weight  of  600 
kilos.  The  average  weight  for  the  radius  in  men  was  334  kilos  ;  in 
women,  220  kilos.  For  the  shatt  of  the  I'ennir,  in  men.  815  kilos  ;  in 
women,  756  kilos.  The  gieatest  weight  withstood  by  the  tibia  was 
650  kilos,  and  the  minimum  was  450  kilos. 

(a)  Fractures  of  Bones. 

Fractures  are  by  far  the  most  couinion  form  of  injury 
to  which  the  bones  are  subject. 

When  a  bone  is  diseased,  the  external  force  required  to 
fracture  it  may  be  so  slight  as  to  be  almost  inappreciable. 
Bones  weakened  by  rachitis,  osteomalacia,  syphilis,  or 
tabes  are  sometimes  broken  by  ordinary  muscular  con- 
tractions. 

A  healthy  bcme,  on  the  other  hand,  possesses  a  high 
degree  of  resistance  to  external  violence,  as  is  shown  by 
the  scale  of  figures  previously  given.  This  power  of 
resistance  varies  with  the  age  of  the  iudividual.  In  chil- 
dren, ossification  being  still  incomplete,  the  bone  is  com- 
paratively flexible,  and  therefore  is  less  subject  to  fracture, 
lu  old  age,  when  atro])hy  has  lowered  the  power  of  resist- 
ance, we  meet  with  fractures  with  comparative  frequency. 

Fractures,  of  course,  occur  most  frequently  among  the 
class  of  people  most  exposed  to  accidents — in  workmen 
between  twenty-five  and  forty-five  years  of  age  M^ho  are 
usually  chosen  for  all  kinds  of  heavy  and  daugerous  labor. 

According  to  Bruns,  the  comparative  frecinency  of  fractures  in  dif- 
ferent periods  of  life  may  be  expressed  by  the  following  table  : 

From  birth  to  the  10th  year 5.9  % 

"      10th       "        20th     " 8.1  " 

"      20th      "       30th     " 12,0  " 

"      30th       "        40th     " 15.4  " 

"      40th      "       50th    " 13.5  " 

"      50th       "        60th     " 14.9  " 

"      60th       "        70th     " 12.3  " 

"      70th      "       90th     " 17.5  " 

(8.7%  in  adecad.) 


Male. 

Female. 

.2.1 

:    J.O 

5.7 

:    1.0 

7.2 

:    1.0 

12.7 

:    1.0 

6.9 

:    1.0 

2.9 

:    1.0 

1.7 

:    1.0 

1.0 

:    1.9 

FRACTURES  OF  BONES.  63 

The  proportion  between  fractures  according  to  sex  is  as  follows  : 

From  birth  to  the  lOth  year 

"  10th  "  20th  " 

"  20th  "  30th  " 

"  30th  "  40th  " 

"  40th  "  50th  " 

"  50th  "  60th  " 

"  60th  "  70th  " 

"  80th  "  90th  " 

According  to  this  table,  fractures  occur,  on  the  average,  four  and  a 
half  times  as  frequently  in  men  as  in  women. 

Fractures  are  divided  into  two  classes — simple  and  compound.  In 
the  latter  the  skin  and  other  soft  tissues  are  so  injured  as  to  form  an 
open  wound,  thereby  giving  entrance  to  pathogenic  bacteria. 

Fractures  are  further  classified  as  complete  and  incomplete  ;  the 
subperiosteal  and  green-stick  varieties  belong  in  the  latter  class. 

In  respect  to  their  origin,  they  are  said  to  be  direct  and  indirect. 
In  indirect  fractures  the  bone  is  alvvaj'S  broken  at  a  distance  from  the 
point  at  which  the  external  force  is  applied  ;  a  fracture  at  the  elbo%v 
or  shoulder,  for  instance,  may  l)e  caused  by  falling  on  the  hand,  or  a 
fracture  of  one  of  the  vertebrae  by  falling  on  the  feet. 

The  line  of  fracture  varies  in  direction  and  extent  in  different  cases  ; 
heuce,  we  speak  of  obli(jue,  transverse,  longitudinal,  and  sj^iral  frac- 
tures, and  also  of  comminuted  and  multiple  fractures. 

Certain  special  forms  of  fracture  deserve  mention,  as  follows  : 

Fractures  caused  by  bending  of  the  bone  :  for  example,  when  a 
wheel  passes  over  a  concavocouvex  l)one,  the  concave  side  being  down. 

Fractures  caused  by  torsion  :  for  example,  a  fracture  of  the  femur 
when  the  individual,  standing  on  his  feet,  is  caught  under  a  falling 
wall,  and  at  the  same  moment  suddenly  and  violently  twists  his  body. 

Fractures  caused  by  compression  :  for  example,  a  fracture  of  the  os 
calcis  or  of  a  vertebra  as  the  result  of  falling  and  landing  on  the  feet. 

Fractures  caused  by  crushing  :  for  example,  when  a  heavy  ol)ject 
falls  on  the  foot. 

Fractures  caused  by  a  tearing  force,  most  frequently  due  to  the 
action  of  muscles,  and  indirectly  to  that  of  ligaments  :  for  example,  a 
fracture  of  the  neck  of  the  femur  as  the  result  of  overtension  of  the 
Y-liganient ;  of  the  patella,  as  the  result  of  overaction  of  the  quad- 
riceps ;  of  the  olecranon,  from  overaction  of  the  triceps,  etc. 

Fractures  caused  by  mangling  :  for  examiile,  when  the  hand  is 
caught  between  cog-wheels. 

Fractures  caused  by  bullet-wounds  or  by  explosions.  With  the 
former  we  have  little  concern  here.  The  fractures,  on  the  other  hand, 
that  are  caused  by  explosions  of  gas-pipes,  of  dynamite  charges,  etc., 
are  met  with  very  frequently  in  accident-practice. 

Without  entering  upon  a  discussion  of  the  symptoma- 
tology of  recent  fractures,  there  is  one  question  that  calls 


64  DISEASES  CAUSED  BY  ACCIDENTS. 

for  consideration  liere.  It  has  often  been  the  subject  of 
controversy  between  physicians  and  trades-unions,  and 
may  be  formulated  as  follows  :  Can  a  person  proceed  on 
his  way  or  go  on  with  his  work  immediately  after  the 
occurrence  of  an  accident  by  which  he  has  suffered — for 
example,  a  fracture  of  the  ankle-joint,  of  a  vertebra,  or  of 
the  clavicle?  We  must  admit  this  to  be  possible.  The 
second  part  of  this  book  contains  a  number  of  instances 
of  this  nature. 

Healing  of  a  fracture  takes  place  by  means  of  the  for- 
mation of  callus  between  and  around  the  broken  ends,  the 
amount  of  callus  formed  varying  greatly  in  different  indi- 
viduals. 

As  the  soft  callus  is  gradually  absorbed,  the  thickening  at  the  point 
of  fracture  and  tlie  abnormal  mobility  grow  less  and  less  noticeable. 
The  period  required  for  complete  consolidation  varies  in  diiferent 
bones  and  with  different  individuals,  and  is  influenced  also  by  many 
minor  circumstances.  Complete  consolidation  is  not  synonymous, 
however,  with  recovery  of  function  ;  to  the  latter  end  careful  and 
regular  exercise  is  necessary. 

In  regard  to  the  published  statements  of  results  of  the  treatment  of 
fracture,  we  must  keep  in  mind  that  systems  of  surgery,  as  a  rule, 
state  the  length  of  time  necessary  for  complete  union  to  take  place, 
whereas  the  later  pul)lications  include  the  time  spent  in  the  recovery 
of  function  by  means  of  medicomechanical  exercises,  etc.,  which  may 
double  the  period  of  treatment.  The  same  distinction  holds  good  in 
regard  to  the  cases  discharged  from  surgical  clinics  as  "cured,"  in 
which  the  "  cure  "  and  the  recovery  of  functional  power  are  two  very 
different  things. 

The  Symptoms  of  Healed  Fractures. — A])art  from 
cicatrices, — which,  of  course,  are  necessary  sequels  of 
compound  fractures, — the  following  points  may  usually  be 
observed  after  healing  of  the  fracture  : 

The  bone  is  still  rather  soft  at  the  point  of  fracture,  and, 
especially  when  the  bone  of  the  leg  is  concerned,  it  is 
swollen  and  thickened.  The  whole  limb  is  somewhat 
swollen,  while  on  the  leg,  and  especially  on  the  foot,  the 
skin  may  be  cyanotic.  The  temperature  of  the  limb  may 
be  raised,  as  can  be  demonstrated  by  a  skin  thermometer ; 
or  it  may  be  lowered  and  nuiy  be  moist  with  cold  perspi- 


FRACTURES  OF  BONES.  65 

ration.  The  limb  is  usually  shortened  and  somewhat  dis- 
placed at  the  point  of  fracture ;  disturbances  due  to  these 
changes  are  often  apparent  in  neighboring  joints,  tendons, 
and  muscles.  The  muscles  of  the  whole  limb  are  atro- 
phied, which  fact  goes  to  prove  the  functional  relation 
existing  among  the  different  groups.  The  palmar  and 
plantar  surfaces  feel  soft,  the  aponeuroses  not  having 
regained  their  normal  tension.  Power  over  the  limb  is 
only  partly  recovered,  and  the  use  of  the  liml)  is  charac- 
terized by  uncertain  and  awkward  movements.  If  the 
fracture  in\-olved  a  joint,  it  will  be  much  swollen,  and 
may  be  inflamed.  The  joint  is  stiff  in  most  cases  ;  and  is 
likely  to  be  so,  indeed,  even  when  not  actually  involved 
in  the  fracture,  if  the  latter  occurred  in  its  immediate 
vicinity.  If  the  nerves  were  injured,  the  resultant  par- 
alyses are  usually  still  very  well  marked.  Patients  often 
complain  of  pain  and  of  being  easily  fatigued. 

Many  of  the  foregoing  symptoms  entirely  disaj)pear; 
others  become  permanent.  The  swellings  and  the  disturb- 
ances of  temperature  gradually  subside,  M'hile  the  callus 
grows  smaller  and  harder,  and  is  usually  absorbed  in  the 
course  of  time.  The  muscles  may  either  partly  or  en- 
tirely recover,  or  the  atrophy  may  permanently  persist,  as 
in  cases  of  ankylosis  or  hypermobility  of  the  joints,  or  of 
paralysis  following  injuries  of  the  nerves.  AVhen  the 
limb  is  shortened,  the  muscles  undergo  the  process  of 
adaptation  to  their  new  requirements.  This  process  may 
require  considerable  time  for  its  completion — in  some 
individuals  as  much  as  one  to  two  years,  or  even  longer. 
Even  if  the  functional  power  of  the  limb  is  only  partly 
regained,  the  patient  learns  how  to  use  it  to  the  best  ad- 
vantage, and  loses  the  ap})earance  of  aAvkwardness  and 
hesitancy  referred  to  before.  The  pain  in  the  limb  gradu- 
ally subsides,  as  a  rule. 

In  some  cases  of  fracture  either  union  never  takes 
place  or  it  is  greatly  delayed.  This  may  be  due  to  a 
variety  of  causes,  such   as   an  insufficient  formation  of 


66  DISEASES   CAUSED  BY  ACCIDENTS. 

callus,  pseudo-arthrosis,  the  interposition  of  soft  parts, 
central  and  periplicral  paralysis,  or  malignant  tumors. 
The  syniptoms  of  unhealed  fractures  are  practically  the 
same  whatever  the  cause,  and  include  a  false  point  of 
motion,  loss  of  functional  power,  atrophy  of  the  whole 
extremity,  especially  l)elo\v  the  fracture,  and  low  tem- 
perature of  the  part. 

The  treatment  of  those  fractures  in  which  healing  is 
delayed,  as  well  as  of  the  part  after  union  has  taken  place, 
is  chiefly  of  a  mechanical  nature,  consisting  of  massage, 
local  baths,  electricity,  and  medicomechanical  exercises. 
The  results  thus  obtained  in  cases  of  delayed  union  and 
false  joints  are  often  remarkable.  Removable  plaster  sup- 
ports for  walking  are  excellent  in  cases  of  pseudo-arthrosis 
of  the  lower  extremity  ;  the  formation  of  callus  is  stimu- 
lated by  the  exercise,  M'hile  in  addition  massage  may  be 
practised  daily.  When  union  is  prevented  by  the  inter- 
position of  soft  parts,  operative  interference  is,  of  course, 
indicated. 

Fractures  Occurring  in  Special  Occupations. — A 
class  of  fractures  of  great  etiologic  interest  is  occasionally 
observed  in  healthy,  vigorous  individuals  as  the  result  of 
a  violent  or  awkward  movement  or  of  a  misstep  while 
carrying  a  heavy  load.  The  neck  of  the  femur  was  the 
seat  of  fracture  in  six  of  the  seven  cases  I  have  collected, 
and  in  all  the  cases  it  was  the  cancellous  portion  of  the 
bone  that  was  involved.  The  following  case,  to  be  again 
referred  to  in  Part  II,  involved  the  os  calcis,  astragalus, 
and  scaphoid  : 

A  stone-carrier,  thirty-nine  years  of  age,  in  good  liealth,  lost  liis 
wooden  shoe  from  the  right  foot  wliile  carrying  a  heavy  load  of  stones 
up  a  ladder,  and  was  obliged  to  mount  five  rungs  with  his  unprotected 
foot.     The  fracture  was  (lemonstrated  by  X-rays. 

There  is  no  connection  between  fractures  of  this  nature 
and  spontaneous  fractures  of  diseased  bones. 

Spontaneous  Fractures. — Under  the  influence  of  cer- 
tain pathologic  processes — such  as  tuberculosis;  syphilis, 


CONTUSIOAS  OF  BONES.  67 

tabes,  osteomalacia,  rachitis,  sarcomatosis,  etc. — the  bones 
become  softened  and  are  very  easily  fractured.  Ordinary 
movements,  such  as  taking  off  the  shoes  or  throwing  an 
object,  may  suffice.  Thiem,  in  his  "■  Miinual,"  has  cited  a 
number  of  these  cases.  I  will  mention  only  a  few,  the 
illustrations  and  detailed  accounts  of  which  will  be  found 
in  Part  II. 

In  one  case  (see  Plate  9)  a  mason,  thirty-four  j'ears  of  age,  felt 
something  crack  in  his  back  on  lifting  a  box  of  lime.  The  injury 
proved  to  be  a  fracture  of  a  lumbar  vertebra.  The  cause  was  tuber- 
culosis. 

In  another  case  a  man  of  similar  age  felt  a  sudden  pain  in  his  right 
foot  after  carrying  stones  up  oue  story.  On  lookiug  at  his  loot  he 
found  it  swollen.  The  diagnosis  was  fracture  of  the  os  calcis  ;  and  the 
cause,  tuberculosis. 

In  a  third  case  a  calciminer,  forty-six  years  of  age,  while  carrying 
a  sack  of  plaster  on  his  back  turned  liis  ankle,  and  in  so  doing  frac- 
tured it.  The  growth  of  callus  was  very  abuudant.  The  diagnosis 
was  fracture  of  the  right  malleolus  ;  and  the  cause,  tabes. 

In  the  last  two  cases  no  damages  were  allowed  the 
patients,  although  spontaneous  fractures  are  covered  by 
the  Accident  Insurance  Law,  as  it  could  not  be  shown 
that  the  injury  was  caused  by  an  accident  in  the  sense  in 
Avhich  the  term  is  understood  by  the  law. 

Fatal  Results  of  Fractures. — Fractures  may  cause 
death  by  reason  of  fat  embolism,  by  the  entrance  of  air 
into  the  circulation,  or,  in  rare  instances,  by  internal 
hemorrhage. 

(b)  Contusions  of  Bones. 

Accidents  such  as  blows,  kicks,  falls,  etc.,  instead  of 
causing  fracture,  may  only  crush  the  part  and  lead  to  an 
acute  traumatic  periosteitis,  and  to  an  inflammation  of  the 
soft  tissues.  Sometimes  the  inflammation  extends  to  the 
medulla  as  well,  but  under  favorable  circumstances  this 
soon  subsides.  Bones  that  are  but  slightly  protected  by 
soft  parts — such  as  tlie  tibia,  for  instance — are  most  liable 
to  attacks  of  traumatic  periosteitis.  In  the  case  of  the 
tibia  the  infiltration  of  the  periosteum  is  easily  demon- 


68  DISEASES   CAUSED  BY  ACCIDENTS. 

strated  by  tlie  iiuk'ntations  left  by  pressure  of  the  fingers. 
Traumatic  periosteitls  yields  readily  to  treatment,  as  a 
rule,  recovery  being  complete  in  from  two  to  four  weeks. 
In  other  cases  the  pain  and  swelling  persist  much  longer, 
and  it  is  necessary  to  keep  the  patient  in  bed  in  order  to 
effect  a  cure. 

Open  wounds  of  the  periosteum  and  of  the  bones  are 
not  dangerous  if  proper  antiseptic  precautions  are  taken. 
Sometimes  when  the  cicatrix  is  attached  to  the  bone,  it 
gives  rise  to  much  pain,  especially  if  nerve-branches  are 
involved  in  its  growth.  In  Part  II  will  be  found  the 
history  of  a  case  of  this  kind,  following  a  contusion  of  the 
tibia,  that  I  have  had  under  observation  for  eight  years. 

Infectious  periosteitis  occurs  as  part  of  an  infectious 
osteomyelitis,  the  involvement  of  the  periosteum  being 
the  most  conspicuous  feature  of  the  disease. 

(c)  Traumatic  Osteomyelitis. 

Although  traumatism  can  not  cause  an  infectious  osteo- 
myelitis without  the  presence  of  the  specific  bacteria,  it 
does  act  as  the  indirect  cause  of  the  disease,  since  the 
injury  done  to  the  tissues  furnishes  the  bacteria  with  the 
conditions  best  suited  to  their  development.  The  injury 
is  not  necessarily  produced  by  violence  :  bodily  strain  or 
exposure  to  severe  cold  may  be  sufficient. 

The  danger  of  infection  through  the  open  wound  of  a 
com]X)und  fracture  does  not  need  emphasis  ;  an  insignifi- 
cant wound  of  the  skin  may,  however,  serve  equally  Avell 
for  the  entrance  of  pathogenic  bacteria  into  the  system. 

After  the  osteomyelitis  subsides,  the  bones  regain  their 
strength  and  usefulness  ;  a  subacute  or  chronic  inflamma- 
tory process  sometimes,  however,  ])ersists  for  years  or  for 
life.  Suppurating  sinuses  leading  down  to  the  medullary 
cavity  and  sequestra  are  features  of  this  chronic  process. 
The  individuals  thus  affected  are  nevertheless  able  to  work, 
unless  an  acute  inflammation  sets  in.  The  following  will 
serve  as  an  example  • 


TUBEECULAS  OSTEITIS.  69 

A  stone-carrier  whom  I  often  had  occasion  to  examine  continued  to 
carry  stones  on  bis  left  shoulder  for  about  sixteen  years,  in  spite  of  the 
existence  of  a  suppurating  sinus  on  the  left  arm,  about  the  width  of 
two  fingers  below  the  surgical  neck  of  the  humerus. 

Ijong-conti lined  suppuration  leads  in  the  end  to  serious 
difficulties.  There  is  an  extensive  growth  of  scar-tissue, 
often  firmly  attached  to  the  bone ;  the  joints  become 
ankylosed ;  disturbances  of  circulation  and  nutrition 
manifest  themselves,  especially  when  the  lower  extremi- 
ties are  involved  ;   the  part  undergoes  atrophy,  etc. 

An  extension  of  infection  through  metastasis  is  an  ever- 
present  danger  in  cases  of  osteomyelitis.  If  a  joint  be- 
comes involved,  its  functional  power  is  apt  to  be  perma- 
nently destroyed. 

When  a  limb  is  the  seat  of  an  osteomyelitis  during 
childhood,  its  growth  is  temporarily  checked,  and  it  may, 
in  consequence,  never  attain  its  full  development. 

The  treatment  of  the  acute  or  subacute  stage  is  purely 
surgical.  When  the  process  has  become  chronic,  only 
symptomatic  treatment  can  be  employed,  as  a  rule.  The 
patients  should  be  instructed  how  to  care  for  the  wound 
when  a  new  abscess  breaks  open,  and  advised  to  consult  a 
physician  as  soon  as  possible.  The  inability  for  self- 
support  must  be  judged  according  to  each  individual 
case. 

(d)  Tubercular  Osteitis. 

Traumatism  plays  the  same  part  in  the  etiology  of  this 
disease  as  in  osteomyelitis.  In  the  majority  of  cases  the 
individual  is  already  tubercular,  although  the  process  may 
be  latent,  and  the  injury  may  be  of  a  very  trivial  nature. 
It  has  been  stated  that  tubercular  osteitis  is  most  likely 
to  develop  after  just  such  injuries.  The  process  is  nsu- 
ally  located  in  the  cancellous  tissue  ;  it  may,  however,  ex- 
tend to  the  compact  bone.  The  articular  surfiices  are 
involved  more  often  than  any  other  part  of  the  bones. 


70  DISEASES  CAUSED  BY  ACCIDENTS. 


II.  INJURIES  AND  TRAUMATIC    DISEASES  OF  THE 
JOINTS. 

(a)  Contusions  of  Joints. 

By  contusion  of  a  joint  is  commonly  understood  an 
injury  of  which  the  only  apparent  effect  is  a  hemorrhage 
into  the  joint.  It  may  be  caused  by  a  kick,  a  fall,  the 
caving-in  of  a  wall  or  of  the  sides  of  an  excavation,  or  by 
blows  from  falling  objects. 

It  is  often  difficult,  when  the  joint  is  much  swollen,  to 
differentiate  between  a  simple  contusion  and  a  fracture  of 
the  joint,  and  in  many  instances  the  latter  is  not  diagnosed 
for  some  time  after  the  injury.  Statistics  collected  since 
X-ray  examinations  came  into  use  show  a  much  diminished 
proportion  of  cases  of  simple  contusion. 

The  effusion  caused  by  a  simple  contusion,  when  treated 
by  rest,  elevation,  and  compresses,  is  generally  rapidly 
absorbed,  and  the  cure  is  completed  in  a  few  weeks. 
When  certain  joints  are  involved,  absorption  may  be 
somewhat  slower,  and  it  is  always  delayed  by  a  too  early 
use  of  the  joint.  The  atrophy  of  the  muscles  connected 
with  the  joint  persists  for  some  time  after  subsidence  of 
the  inflammation  and  absorption  of  the  effusion,  but  can 
be  overcome  by  conscientious  use  of  massage,  medico- 
mechanical  exercises,  and  electricity.  In  some  cases,  par- 
ticularly in  those  in  which  absorption  of  the  effusion  is 
delayed,  movement  of  the  joint  calls  forth  rubbing,  crack- 
ing sounds,  which  are  doubtless  due  to  hypertrophy  and 
proliferation  of  the  synovial  folds  and  fringes,  in  combina- 
tion with  a  subnormal  secretion  of  synovial  fluid.  The 
condition  is  not,  as  a  rule,  painful,  nor  does  it  interfere  to 
any  appreciable  degree  with  the  action  of  the  joint. 

(b)  Sprains. 
Two  varieties  of  sprains  can  be  distinguished.      In  the 
first  variety  the  articular  ends  of  the  bones  suffer  a  mo- 


SPRAINS.  71 

mentarv  niiitiial  dit^plaeement,  hv  reason  of"  which  the 
ligaments  ot"  the  joint  are  strained,  and  both  hganients  and 
capsule  are  soniewliat  torn.  Numerous  small  hlood-vessels 
are  torn  across  at  the  same  time,  and  an  effusion  of  blood 
into  the  joint  results  in  consequence.  Swelling  and  inflam- 
mation of"  the  joint  naturally  follow.  In  the  second 
variety  the  articular  surfaces  are  injured  l)y  being  struck 
against  each  other.  While  the  outward  symptoms — swell- 
ing, effusion,  inflammation,  and  ])ain — are  the  same  as  in 
the  first  variety,  the  capsule  and  ligaments  remain  intact. 

The  injury  resulting  from  sj)rains  is  not  necessarily  con- 
fined to  the  soft  tissues  and  to  an  effusion  of  blood.  In 
man>^  cases  the  term  includes  a  fracture  as  well,  and  in  con- 
sequence of  the  extreme  strain  upon  the  ligaments  at  the 
time  of  the  accident,  a  bit  of  the  bone  is  not  infrequently 
torn  off  at  one  of  their  points  of  insertion. 

Sprains  are  apt  to  heal  more  slowly  than  simple  contu- 
sions of  the  joint.  In  many  cases  the  result  remains 
unsatisfactory  in  spite  of  a  long  course  of  treatment.  This 
is  sometimes  due  to  the  development  of  tuberculosis, 
sometimes  to  the  existence  of  a  subluxation  that  has 
occurred  subsequently  to  the  original  injury.  Poor 
results  are  in  some  cases  to  be  ascribed  to  too  prolonged  a 
use  of  fixation-l)andage,  which  leads  to  partial  ankylosis. 
Loose-jointedness  is  another  evil  sequel  of  sprains  that  is 
occasionally  met  with.  The  condition  may  depend  on  the 
laceration  of  a  ligament  or  of  the  capsule,  or  on  the  fact  of 
a  bit  of  bone  or  cartilage  having  been  pulled  off  by  a  liga- 
ment, wiiich  remains  unattached  in  consequence.  The 
loose  bit  of  bone  or  cartilage  acts  as  a  foreign  body  in  the 
joint,  causing  great  pain  at  times. 

The  treatment  of  sprains  is  the  same  as  that  for  contu- 
sions ;  muscular  atropliy  and  stiffness  of  the  joints  demand 
after-treatment,  and  loose-jointedness  is  to  be  overcome  by 
the  restriction  of  a  suitable  bandage. 


72  DISEASES   CAUSED  BY  ACCIDENTS. 


(c)  Dislocations  of  Joints. 

While  in  case  of  sprains  the  articular  surfaces  immedi- 
ately right  themselves,  in  dislocations  they  remain  sepa- 
rated after  displacement  until  artificial  reduction  is  prac- 
tised. The  separation  of  the  articular  surfaces  is  neces- 
sarily associated  with  more  or  less  extensive  laceration  of 
the  capsule  and  ligaments.  The  laceration  of  the  capsule, 
at  all  events,  is  a  regular  accompaniment  of  a  dislocation. 
Blood-vessels,  and  very  often  branches  of  nerves,  are  torn, 
while  pieces  of  bone  are  chipped  off  at  the  same  time,  in 
which  case  the  term  luxation-fracture  is  perfectly  a]ipli- 
cable.  The  swelling  that  takes  place  in  consequence  of  a 
dislocation  may  not  be  ap})reciably  greater  than  that  seen 
after  sprains. 

The  degree  of  force  required  for  the  reduction  of  a  dis- 
location often  exceeds  that  which  produced  the  injury  ; 
the  process  of  reduction,  therefore,  is  not  unattended  by 
danger.  The  capsule  and  ligaments  may  be  further  lacer- 
ated, bits  of  bone  may  be  chipped  oflP,  or  nerves  may  be 
torn.  After  reduction  the  joint  and  the  neighboring  tis- 
sues appear  swollen.  Swelling  and  ecchymosis  are  still 
seen  at  the  time  when  the  fixation-bandage  is  removed  ; 
and  if  the  part  has  been  kept  immobilized  for  any  length 
of  time,  the  nearest  other  joint  of  the  limb  will  show 
only  limited  mobility,  while  the  aflPected  joint  itself  is 
completely  stiifencd.  When  the  shoulder-joint  has  been 
thus  treated,  for  instance,  tlie  arm,  after  removal  of  the 
bandage,  will  be  found  to  be  fixed  at  the  annle  at  which 
it  was  held,  while  the  moljility  of  the  elbow  is  restricted. 
The  muscles  about  the  joint,  as  well  as  those  extending 
over  the  next  joint,  are  seen  to  be  ati'ophicd.  In  case  of 
injury  to  the  nerves,  paralysis  of  the  parts  supplied  by 
them  will  become  evident,  the  permanence  of  the  paralysis 
depending  on  the  severity  of  the  injury.  Mobility  of  the 
joint  can  often  be  restored  by  treatment ;  in  many  cases, 
however,  partial  ankylosis  is  caused  by  cicatricial  contrac- 


SUBLUXATION.  73 

tion  of  the  lacerated  capsule.  The  limb  necessarily  assumes 
an  abnormal  position  in  consequence  of  these  contractions 
of  the  capsule  ;  the  muscles  and  tendons  become  disj)laced 
and  undergo  atrophy.  Occasionally,  the  position,  by  indi- 
cating the  point  of  rupture  of  the  capsule,  gives  a  clue  to 
the  variety  of  the  dislocation.  In  favorable  cases  the 
ankylosis  can  be  overcome  by  treatment ;  in  others,  it 
remains  permanent. 

Sometimes,  instead  of  ankylosis  we  have  hypermobility 
of  the  joint — loose-jointodness. 

The  principal  therapeutic  indication  is  the  recovery 
of  normal  mobility,  which  condition  is  best  achieved  by 
means  of  passive  and  active  exercise,  carried  out  by  the 
operator  and  on  an  appropriate  apparatus.  The  atrophy 
is  overcome  at  the  same  time.  Massage  is  helpful  for  the 
atroj)hy,  but  is  of  little  use  in  the  end  unless  mobility 
of  tlie  joint  is  regained.  Exercise,  massage,  and,  above 
all,  electricity,  are  to  be  recommended  for  the  paralysis. 
Hypermobility  must  be  treated  by  means  of  a  suitable 
bandage. 

Subluxation. 

This  injury  frequently  escapes  diagnosis,  and  being  dis- 
missed as  a  contusion  or  a  strain,  the  displacement  is  not 
reduced.  In  other  cases  an  even  more  harmful  blunder 
is  made  :  that  of  diagnosing  a  fracture  of  the  joint  and 
immobilizing  the  latter.  Hence,  the  consequences  of  sub- 
luxation are  apt  to  be  serious.  While  the  joint  remains 
swollen,  it  is  difficult  to  recognize  the  displacement ;  as  the 
swelling  goes  down,  the  displacement  becomes  more  and 
more  evident.  Diagnosis  is  less  difficult  in  the  more 
severe  cases  that  approach  complete  dislocations ;  and  in 
these  reduction  is,  of  course,  practised.  In  some  situa- 
tions— in  the  knee-joint,  for  example — a  subluxation 
closely  resembles  a  healed  fracture  of  the  condyle. 

The  characteristic  signs  of  subluxation  are  as  follows  : 
There  is  mutual  dis]ilacement  of  the  articular  surfaces, 
varying  in  degree.     The   surfaces  remain  for  the  greater 


74  DISEASES   CAUSED  BY  ACCIDENTS. 

part  in  contact  with  each  other ;  the  displacement  may  be 
entirely  lateral  or  it  may  be  partly  rotatory,  the  muscles 
and  tendons  connected  with  the  joint  being  disi)laced 
accordingly.  The  appearance  of  the  joint  is  changed  :  it 
is  enlarged,  and  its  outlines,  depressions,  and  folds  are  less 
marked  than  normal  ;  the  muscles  with  which  it  stands 
in  relation  have  atro})hied.  The  joint  is  usually  flexed. 
Mobility  is  impaired  ;  it  is,  however,  never  entirely  lost. 
IVIotion  is  painful,  the  pain  having  a  lasting  character. 
The  joint  may  remain  in  a  state  of  inflammation  for  a  long 
time  ;  massage  and  exercises,  unless  very  cautiously  em- 
ployed, are  apt  to  increase  and  to  prolong  the  disturbance. 

As  regards  treatment,  the  first  aim  is  to  subdue  the 
inflammation  by  means  of  rest,  favorable  position,  and 
compresses.  Afterward,  when  the  exact  relation  of  the 
articular  surfaces  has  been  clearly  determined,  exercise 
may  be  begun  with  great  caution.  I  have  found  move- 
ments of  resistance  to  gradually  increased  force  to  be 
especially  valuable.  If  the  pain  grows  worse,  exercise 
should  be  curtailed.  Muscular  atrophy  is  treated,  as 
usual,  with  massage  and  electricity.  The  results  of  treat- 
ment are  often  excellent,  but  not  in  all  cases  ;  the  condi- 
tion of  the  patient  is  often  only  })artly  relieved  by  a  long 
course  of  treatment,  and  sometimes  the  pain  is  not  in  the 
least  subdued. 

Fractures  of  Joints. 

The  prognosis  for  fractures  involving  joints  is  much 
less  favorable  than  for  fractures  of  the  shaft  of  the  bone. 
The  reason  for  this  lies  in  the  structure  of  the  joint  itself. 
The  articular  cartilages,  lined  with  synovial  membrane, 
are  fractured  no  less  than  the  bone,  and  an  inflammatory 
exudate  is  poured  out  into  the  joint.  The  most  urgent 
indications,  therefore,  are  to  allay  the  inflannnation  and  to 
cause  the  absorption  of  the  exudate  and  the  union  of  the 
fractured  parts.  All  energetic  mechanical  treatment  hav- 
ing for  its  design  the  preservation  of  function  in  the  joint 
must,  therefore,  be  delayed.      Under  these  conditions  it  is 


FRACTURES   WITH  DISLOCATION.  75 

often  quite  impossible  to  prevent  permanent  ankylosis, 
especially  when  muscular  action  causes  dislocation  of  the 
fractured  parts  of  the  joint.  It  is  advisable,  in  view  of 
the  foregoing,  to  begin  careful  passive  movements  of  the 
joint  at  the  earliest  possible  moment — as  soon,  in  fact,  as 
the  inflammation  and  exudation  subside.  Certain  active 
movements  are  also  permissible. 

The  prognosis  is  more  favorable  for  fractures  that  occur 
in  the  vicinity  of  the  joint  but  do  not  actually  involve  it. 
The  prevention  of  ankylosis  in  these  cases  is  a  less  diffi- 
cult matter,  but  there  are  a  number  of  causes  that  lead  to 
it,  nevertheless.  Sometimes  the  inflammation  extends  to 
the  joint,  or  there  may  be  a  dislocation  of  the  latter  sec- 
ondary to  a  similar  complication  at  the  point  of  fracture  ; 
in  other  cases  the  continued  immobilization  of  the  joint 
necessitated  by  the  treatment  in  itself  suffices  to  produce 
ankylosis.  The  limb  is  often  fixed  at  an  angle.  A  dislo- 
cated and  ankylosed  joint  is  of  unfavorable  prognosis  as 
to  function  ;  but  if  movement  can  be  begun  early,  it  is 
often  possible,  with  patience  and  unremitting  attention,  to 
overcome  the  adhesions. 

Fractures  with  Dislocation. 

This  double  injury  occurs  with  comparative  frequency  ; 
it  is  seen  in  classic  form  in  fractures  of  the  vertebrae,  espe- 
cially in  the  cervical  and  lumbar  regions  ;  of  the  joints  of 
the  extremities,  the  elbow  is  the  one  most  liable  to  be  in- 
volved. The  prognosis  depends  almost  entirely  on  the 
skill  shown  in  reduction  and  fixation.  If  improperly 
treated  or  if  left  unreduced,  complete  ankylosis  is  sure  to 
follow. 

If  by  refracturing  an  ankylosed  joint  it  can  be  fixed  at 
an  angle  more  favorable  to  the  usefulness  of  the  limb,  the 
operation  sliould  be  strongly  urged.  An  arm  fixed  at  a 
right  angle  at  the  elbow,  for  examj^le,  is  a  comparatively 
useful  member,  while  it  is  less  and  less  so  the  straighter  it 
becomes. 


76  DISEASES  CAUSED  BY  ACCIDENTS. 


Traumatic  Arthritis. 

This  develops  as  a  result  of  contusions,  sprains,  and 
dislocations,  of  fractures  not  only  of  the  joint  itself,  but 
occurring  in  its  immediate  vicinity,  and  of  cellulitis,  etc. 
Arthritis  is  often  to  be  regarded  as  a  symptom  of  one  of 
the  injuries  enumerated  ;  the  prognosis  is  generally  favor- 
able for  a  ra])id  recovery,  but  with  advancing  years  there 
is  a  tendency  for  the  acute  inflammation  to  develop  into  a 
chronic  form.  In  chronic  arthritis  the  joint  is  enlarged 
and  there  is  a  proliferation  of  the  synovial  folds  of  the 
cai3sule,  which  causes  the  well-known  cracking  sounds  on 
motion.  In  some  individuals  there  seems  to  exist  a  ten- 
dency toward  such  proliferation.  Chronic  arthritis  is  not, 
as  a  rule,  painful  ;  nor  does  it  interfere  to  any  marked 
extent  \vith  the  mobility  of  the  joint.  If  the  inflammation 
becomes  tubercular  or  purulent,  however,  or  if  it  is  super- 
seded by  an  arthritis  deformans,  the  case  is  thereby  given 
a  serious  aspect. 

Articular  Rheumatism,  Gout,  and  Arthritis  Deformans. 

Traumatism  may  act  as  the  indirect  cause  of  acute 
articular  rheumatism  by  lowering  the  resistance  of  the 
joint,  thereby  rendering  it  more  susceptible  to  attack  by 
the  cocci  of  the  disease. 

The  question  of  the  traumatic  origin  of  gout  can  be 
similarly  explained.  It  is  beyond  doubt,  on  the  other 
hand,  that  arthritis  deformans  can  develop  as  a  direct 
sequel  of  traumatism.  While  fractures  are  the  most  com- 
mon form  of  injury  leading  to  the  disease,  it  may  also 
develop  after  contusions,  sprains,  and  dislocations.  Being 
a  chronic  disease,  it  develops  slowly  ;  yeai's  may  elapse 
before  the  deformity  that  it  causes  reaches  an  extreme 
degree.  The  synonym  of  *'  arthritis  pauperum,"  which 
is  applied  to  the  disease,  is  doubtless  based  on  the  fact 
that  it  is  most  frequently  seen  in  working-men  who  do 
hard  work   and  live  poorly.     There  is  no  doubt  that  the 


TUBERCULAR  ARTHRITIS.  77 

development  of  arthriti.s  deformans  is  favored  by  the 
eifects  of  hard  labor,  especially  when  undertaken  too  soon 
after  an  injury,  l)efore  the  joint  has  completely  recovered, 
in  combination  with  lack  of  care  and  poor  and  innutritions 
food.  The  injuries,  whether  of  trivial  or  serious  nature, 
to  which  the  joint  is  exposed  during  work  or  at  other 
times  are  also  of  etiologic  importance. 

A  joint  aifected  by  arthritis  deformans  gradually  be- 
comes misshapen  ;  its  power  of  motion  is  diminished,  and 
in  the  end  is  completely  lost.  The  articular  ends  of  the 
bone  in  a  well-developed  case  are  in  part  atrophied,  in 
part  covered  with  hypertrophic  processes,  while  ligaments 
and  tendons  have  undergone  ossification — a  condition  that 
is  well  expressed  by  the  term  osteo-arthritis.  The  disease 
entails  a  great  deal  of  suifering  at  times,  especially  aggra- 
vated by  the  presence  of  free  ossified  nodules  in  the  joint. 

The  prognosis  as  to  usefulness  of  the  joint  is  very 
bad  ;  the  disease  is  incurable,  although  some  relief  may 
be  gained  by  means  of  baths,  compresses,  inunctions,  and 
rest.  Massage  should  not  be  attempted.  Affected  indi- 
viduals can  not  do  heavy  work,  but  are  often  able  to  per- 
form light  tasks. 

Tubercular  Arthritis. 

By  causing  inflammation  of  a  joint,  traumatism  may 
be  indirectly  responsil)le  for  the  subsequent  development 
of  tuberculosis  in  tlie  same.  There  are  two  Avays  in 
which  infection  of  the  joint  may  occur  :  In  a  tubercular 
individual  the  tubercle  bacilli  may,  by  the  process  of 
metastasis,  establish  themselves  at  the  site  of  injury, 
the  resistance  of  the  tissues  having  been  lowered  by  in- 
flammation ;  or  there  may  be  a  primary  tubercular  arthri- 
tis as  the  result  of  infection  subsequent  to  the  injury. 

Tubercular  arthritis  is  more  frequently  observed  after 
comparatively  sliglit  injuries,  such  as  contusions  and 
sprains,  than  after  those  of  a  more  serious  nature,  such  as 
fractures.     As    fractures,   however,   are    doubtless    over- 


78  DISEASES  CAUSED   BY  ACCIDENTS. 

looked  ill  many  cases  of  so-called  sprains,  their  probable 
influence  on  the  development  of  the  tubercular  process 
must  be  admitted.  I  have  myself  observed  a  number 
of  cases  of  tubercular  artliritis  following  fracture.  Con- 
ditions favorable  to  the  development  of  tuberculosis  pre- 
vail among  working  people,  who  do  hard  work  and  eat 
poor  food,  and  scarcely  enough  of  that,  while  they  drink 
regularly  and  to  excess.  They  live  from  hand  to  mouth, 
are  frequently  out  of  work,  and  at  such  times  are  likely 
to  drink  more  heavily  tlian  usual.  The  dwellings  in 
which  they  live  are  poorly  built,  and  are  frequently  infected 
with  tubercle  bacilli,  while  tuberculous  and  healthy  mem- 
bers of  a  family  live  together  in  close  companionship.  It 
is  not  to  be  wondered  at  that  a  vigorous  working-man  who 
is  confined  to  his  room  for  a  time  by  a  sprained  ankle,  for 
instance,  should,  under  such  conditions,  develop  a  tuber- 
cular arthritis.  Its  development  is  favored,  moreover, 
by  a  too  early  use  of  the  injured  joint. 

Tubercular  arthritis  is  characterized  by  its  slow  course 
and  its  resistance  to  all  methods  of  treatment.  When  it 
develops  in  consequence  of  an  injury,  it  is  not  easily  recog- 
nized in  its  early  stages,  and  considerable  time — in  some 
cases  as  much  as  a  year — may  elapse  before  a  positive 
diagnosis  can  be  made.  The  symptoms  pointing  to  the 
disease  are  pain,  swelling,  and  diminished  mobility  of  the 
joint,  with  gradual  changes  in  its  shape.  The  general 
health  deteriorates  at  the  same  time,  and  the  patient  loses 
flesh  ])erceptibly.  Tubercular  arthritis  can  be  diagnosed 
by  means  of  X-ray  photographs  before  the  general  symp- 
toms become  apparent. 

The  time  required  for  the  development  of  the  disease 
after  the  occurrence  of  the  injury  is  variable.  The  pro- 
cess may  begin  as  soon  as  the  acute  symptoms  of  the  trau- 
matism subside,  or  it  may  not  appear  for  years  afterward. 
In  one  case  of  dislocation  of  the  scaphoid  that  was  under 
my  observation  five  years  elapsed  before  the  tuljcrcular 
process,  which  attacked  the  whole  tarsus,  became  evident. 


RESECTION  OF  JOINTS.  79 

It  is  hardly  necessary  to  state  that  the  prognosis  of 
tubercular  arthritis  is  unfavorable.  We  must  not  be  mis- 
led by  occasional  remissions  during  which  the  swelling 
and  pain  somewhat  diminish,  for  the  disease  is  very  liable 
to  crop  out  in  another  spot,  which  it  reaches  by  metastasis. 

In  treating  cases  of  tubercular  arthritis  we  should 
strictly  avoid  all  active  mechanical  procedures,  such  as 
massage  and  movements  of  the  Joint,  since  by  these 
the  inflammation  is  aggravated.  Good  nourishment  and 
favorable  surroundings  are  the  best  therapeutic  agencies. 

Arthropathy. 

The  affection  of  the  joints  that  occurs  in  syringomyelia, 
and  more  especially  in  tabes,  under  the  name  of  arthrop- 
athy, may  be  directly  caused  by  traumatism.  The  bones 
that  are  affected  by  the  diseases  just  named  become  so 
fragile  that  the  ankle-joint,  for  instance,  may  be  fractured 
by  a  wrench  due  to  a  misstep.  There  is  an  excessive 
growth  of  callus  in  these  cases,  leading  to  deformity  of  the 
joint.  In  tabetic  patients  the  callus  is  quite  characteristic 
of  the  disease. 

In  respect  to  treatment,  we  are  powerless  to  do  more 
than  relieve  the  condition  of  the  patient  to  a  certain 
extent ;  results  in  this  limited  field  are  often  quite  satis- 
factory. 

Resection  of  Joints. 

The  most  important  points  connected  with  ankylosis 
and  loose-jointedness  have  already  been  discussed.  It 
remains  to  mention  the  conditions  that  follow  resection. 
As  a  result  of  the  operation  we  may  have  to  deal  Avith  a 
rigid  joint,  a  loose  joint,  or  a  newly  formed  mobile  joint. 
The  chief  objects  of  the  operation  are  to  remove  the  dis- 
eased or  useless  portion  of  a  joint  and  to  leave  the  part  in 
as  serviceable  a  condition  as  j)<)sslbl('.  If  a  stifl'  joint  is 
to  be  provided,  it  is  to  a  certain  extent  in  the  power  of  the 
surgeon  to  fix  it  in  the  most  advantageous  position.     If, 


80  DISEASES  CAUSED  BY  ACCIDENTS. 

because  of  the  removal  of  a  large  portion  of  the  joint,  the 
operation  results  in  loose-jointedness,  the  usefulness  of  the 
limb  is,  as  a  rule,  greatly  impaired.  A  workman  in  excel- 
lent health,  whose  case  I  have  observed  for  about  nine 
years,  has  an  elbow-joint  in  this  condition.  He  is  obliged 
to  wear  a  jointed  support,  l)y  the  aid  of  which  he  is  able 
to  move  his  arm  a  little  ;  without  it,  the  arm  hangs  help- 
less at  his  side. 

Only  a  very  liinited  degree  of  motion  can  be  expected 
after  resection,  but  it  often  suffices  to  facilitate  the  use  of 
the  limb  as  a  whole. 


12.  THE  INFLUENCE  OF  TRAUMATISM  ON  THE  DEVEL= 
OPMENT  OF  TUMORS. 

Among  the  malignant  tumors  that  belong  under  this 
heading  there  are  only  two  that  demand  our  special  atten- 
tion :  namely,  the  carcinomata  and  the  sarcomata.  [For 
a  very  instructive  clinical  and  ])athologic  study  on  the  in- 
fluence of  traumatisms  in  the  development  of  sarcomata, 
see  W.  B.  Coley's  article  on  "  The  Relation  between  Injury 
and  Sarcoma,"  "  Annals  of  Surgery,"  March,  1898. — Ed.] 

The  process  of  development  differs  in  the  two  varieties 
of  tumor.  In  some  individuals  the  irritation  and  inflam- 
matory reaction  following  traumatism  seem  sufficient  cause 
for  the  development  of  a  sarcoma  in  hitherto  normal  tissue. 
A  carcinoma,  on  the  other  hand,  finds  its  starting-point  in 
scar-tissue  ;  whether  this  has  grown  as  the  result  of  trau- 
matism or  of  disease  is  a  matter  of  no  conse(|uence. 
Constant  irritation  or  repeated  traumatism  may  so  aflect 
the  scar-tissue  as  to  cause  or  favor  the  development  of 
carcinoma.  Traumatism  may,  furthermore,  hasten  the 
development  of  a  growing  carcinoma,  or  it  may  lead  to 
sudden  death  by  loosening  bits  of  the  cancerous  tissue, 
which  are  then  carried  into  the  circulation. 

The  dangers  involved  in  the  growth  of  carcinomata  do 
not  need  emphasis.     In  respect  to  sarcomata,  it  should  be 


CASES  OF  POISONING.  ■  81 

remembered  that  when  they  develop  in  bones,  the  hitter 
become  extremely  liable  to  spontaneous  fracture.  Mention 
of  cases  of  carcinoma  and  sarcoma  for  which  insurance 
was  allowed,  traumatism  having-  been  recognized  as  the 
indirect  cause  of  the  disease,  can  be  found  in  the  annals 
of  the  State  Insurance  Bureau. 


13.  CASES  OF  POISONING. 

Accidents  due  to  poisoning  are  included  in  the  list  of 
accidents  for  which,  according  to  the  Accident  Insurance 
Law,  payment  of  insurance  may  be  demanded.  The  poi- 
soning of  miners  l)y  carljon  monoxid,  or  of  watchmen  in 
new  buildings  by  the  same  gas,  poisoning  by  benzol  and 
benzin,  poisoning  en  masf^e  by  chlorin  or  by  the  fumes  of 
petroleum  products,  are  all  instances  of  such  accidents. 
We  have  not  space  to  discuss  the  symptomatology  of  such 
cases.  The  law  applies  more  especially,  however,  to  cases 
of  poisoning  incidental  to  employment  in  special  trades 
and  manufactures,  which  are  really  better  looked  upon  as 
diseases  peculiar  to  such  trades. 

Alcoholic  Intoxication  (Chronic  Alcoholism). 

Alcoholic  intoxication  is  so  wide-spread  an  evil  among 
working  people  that  it  deserves  some  discussion  here. 
The  evil  is  so  firmly  implanted  in  all  grades  of  society 
that  it  may  well  l^e  regarded  as  a  national  disease.  Alco- 
hol is  thought  by  working-men  to  be  a  proper  and  essen- 
tial article  of  diet.  It  is  not  in  place  here  to  cite  statistics 
relative  to  the  consumption  of  alcohol  and  the  conse- 
quences of  the  same.  We  should,  however,  bear  its 
effects  in  mind,  especially  as  they  relate  to  the  causation 
of  injuries,  and  as  they  influence  the  prognosis.  Acute 
alcoholic  intoxication  unquestionably  leads  to  many  acci- 
dents. 

Chronic  alcoholic  intoxication,  or  chronic  alcoholism, 
plays  no  less  important  a  part  in  the  etiology  of  accidents, 
6 


82  DISEASES   CAUSED  BY  ACCIDENTS. 

entailing,  as  it  does,  a  loss  of  power  of  body  and  mind, 
thereby  rendering  the  individual  more  liable  to  injury. 
Chronic  alcoholism  does  not  necessarily  imply  frequent 
drunkenness.  The  regular  daily  consumption  of  small 
quantities  of  alcohol,  especially  in  the  form  of  whisky, 
very  often  suffices  to  cause  the  disease  in  individuals  who 
have  never  been  drunk  in  their  lives.  Nor  does  it  always 
depend  on  the  amount  regularly  consumed  :  weak,  ill- 
nourished,  or  nervous  individuals,  or  those  in  whom  there 
is  a  hereditary  predisposition,  develop  symptoms  of  alco- 
holism after  taking  relatively  small  quantities,  and  in 
much  less  time  than  others  of  naturally  strong  constitu- 
tion. The  cumulative  action  of  alcohol  is  easily  under- 
stood if  we  remend)er  that  traces  of  the  poison  can  be 
demonstrated  from  three  to  seven  days  after  its  introduc- 
tion into  the  system  on  a  single  occasion.  Considering 
that  alcohol  is  taken  regularly  into  the  system  for  years, 
as  is  the  custom  among  some  working-men,  who,  more- 
over, live  poorly,  and  often  suffer  deprivation,  the 
development  of  the  synq)toms  of  chronic  alcoholism  at 
one  time  or  another  seems  unavoidable.  The  symptoms 
of  the  disease  are  manifold,  and  consist  chiefly  of  patho- 
logic changes  of  various  organs,  as  follows  : 

1.  The  nervous  system,  including  :  («)  Central  disturb- 
ances (delirium  tremens,  paranoia,  ])aralytic  dementia,  epi- 
lepsy). [This  statement  should  be  somewhat  qualified. 
Alcoholism,  complicated  or  uncomplicated  by  traumatism, 
may  cause  an  almost  endless  chain  of  mental  symptoms  ; 
but  it  can  hardly  be  said  to  cause  either  paranoia  or  para- 
lytic dementia.  Epileptiform  convulsions  also,  when  in- 
duced by  alcohol,  ditfer  in  important  particulars  from  true 
epilepsy.  All  three  of  these  diseases  are  essentially  incur- 
able, whereas  in  the  majority  of  cases  symptoms  caused  by 
alcohol  disappear  upon  the  withdrawal  of  the  poison. — 
Ed.]      (6)  Peripheral  disturbances  (alcoholic  neuritis). 

2.  The  circulatory  system. 

3.  The  respiratory  tract. 


I 


INFECTIOUS  DISEASES.  ^  83 

4.  The  digestive  tract. 

5.  Muscular  system. 

Any  one  group  of  symptoms  may  predominate  in  a 
given  patient.  It  would  lead  us  too  far  to  enter  upon  a 
discussion  of  the  far-reaching  symptomatology  of  the  dis- 
ease. ]\Iany  diseases  of  the  nervous  system,  including 
those  of  traumatic  origin,  display  symptoms  similar  to 
those  of  chronic  alcoholism,  which  may,  in  fact,  be  the 
underlying  cause  of  these  same  nervous  diseases.  We 
need  only  to  study  insane  and  criminal  statistics  to  appre- 
ciate that  alcoholism  is  responsible  for  the  development  of 
many  mental  diseases.  A  regular  consumption  of  alcohol 
leads  also  to  heart-disease,  while  its  evil  eifects  can  be 
directly  or  indirectly  traced  in  the  history  of  cases  of  pul- 
monary tuberculosis,  gastric  ulcers,  diseases  of  the  liver, 
kidneys,  and  other  organs. 

We  frequently  meet  with  some  of  these  conditions  in 
patients  we  see  in  accident-practice.  In  examining  a 
patient  after  injuries  it  is  not  only  valuable,  but  usually 
quite  essential,  before  forming  an  opinion  of  his  case  to 
ascertain  his  habits  regarding  the  use  of  alcohol.  It  is  a 
good  plan  to  question  him  as  to  his  manner  of  living,  to 
cause  him  to  tell  Avhat  he  eats  and  drinks,  as  in  this  way 
we  gain  a  knowledge  of  his  social  status  that  may 
greatly  influence  our  judgment  of  the  case. 


14.  INFECTIOUS  DISEASES. 

Traumatism  may  stand  in  either  direct  or  indirect  rela- 
tion to  infectious  diseases ;  in  the  former  instance  the 
infectious  material  enters  the  body  through  wounds  of  the 
skin,  which  may  be  serious  or  ver\'  trivial,  as  in  case  of 
phlegmonous  inflammation  following  sligiit  injuries  of  the 
finger.  The  same  holds  good  of  other  infectious  processes, 
such  as  malignant  ])ustule,  tetanus,  glanders,  and  malig- 
nant edema.  The  relation  between  traumatism  and  infec- 
tious process  is  none  the  less  direct  when  the  infectious 


84  DISEASES  CAUSED  BY  ACCIDENTS. 

bacteria  enter  a  wound  some  time  after  the  injury.  This 
occurs  in  cases  of  erysipelas,  for  instance.  The  very  fact 
that  the  local  entrance  of  the  bacteria  of  the  diseases  pre- 
viously named  presupposes  the  existence  of  a  wound  is  suf- 
ficient evidence  of  itself  of  the  direct  relation  that  exists 
between  traumatism  and  the  infectious  process.  Tuber- 
culosis of  the  skin  may  develop  similarly,  as  the  result  of 
direct  implantation.  We  are,  therefore,  warranted  in 
speaking  of  a  tuberculosis  of  the  skin  of  traumatic  origin. 

The  relation  between  traumatism  and  the  infectious 
process  is,  on  the  other  hand,  an  indirect  one  in  cases  of 
tuberculosis  of  the  lungs  and  joints,  in  which  the  tubercle 
bacilli  enter  the  body  by  way  of  the  resjiiratory  or  diges- 
tive tract.  Traumatism  serves  to  lessen  the  resistance  of 
the  part  on  which  it  acts,  which  is,  in  consequence,  subject 
to  attack  by  the  tubercle  bacilli  circulating  in  the  blood. 

The  bacilli  of  anthrax  may  enter  the  body  through  the 
respiratory  and  digestive  tracts,  as  well  as  through  wounds. 
According  to  the  State  Insurance  Bureau,  all  such  cases 
are  regarded  as  accidents.  Anthrax  bacilli  are  found  on 
the  skin,  wool,  and  hair  of  an  animal  suflPering  from  the 
disease,  also  on  brushes  made  from  such  hair.  The  dis- 
ease develops  as  a  local  affection  of  the  skin  under  the 
name  of  malignant  pustule ;  when  it  attacks  the  lungs  or 
intestine,  it  is  known  as  "  wool-sorters'  disease."  Cattle 
and  sheep  are  the  animals  most  subject  to  the  disease  ;  in 
human  beings  it  is,  therefore,  most  often  seen  in  butchers, 
farmers,  shepherds,  tanners,  brush-makers,  and  produce 
dealers. 

The  incubation  period  of  malignant  pustule  is  three 
days.  If  it  remains  localized,  it  is  curable  ;  but  if  infec- 
tion becomes  general,  the  prognosis  is  very  grave. 

Symptoms At  first  there  is  a  small  pustule  sur- 
rounded by  a  reddened  area.  The  pustule  rapidly  dries 
up,  leaving  a  blackened  scab.  The  surrounding  tissue  is 
much  indurated.  The  induration  spreads  raj)idly  until 
the  whole  extremity  becomes  the  seat  of  an  intense,  brawny 


INFECTIOUS  DISEASES.  85 

edema.  The  lymph-nodes  are  swollen.  If  the  course  of 
the  disease  is  favorable,  the  scab  gradually  separates  and 
is  thrown  oif.  Progressive  edema  and  high  fever  are  un- 
favorable signs  :  they  are  liable  to  be  followed  by  delirium, 
diarrhea,  rapid  loss  of  strength,  ending  fatally  within  a 
week. 

Prognosis. — Ninety  per  cent,  of  these  cases  recover. 

Wool-sorters'  disease,  as  the  name  indicates,  affects 
those  who  spend  their  working  hours  in  close  contact  with 
wool,  and  contract  the  infection  by  inhalation  of  anthrax 
spores.  Persons  handling  infected  skins  and  hides  are 
exposed  to  the  same  danger.  The  symptoms  are  those  of 
a  septic  bronchopneumonia  ;  anthrax  spores  can  be  dem- 
onstrated in  the  sputum.  The  onset  is  marked  by  a 
chill,  fever  rising  to  40°  C,  soon  followed  by  the  low 
temperature  of  collapse.  The  subjective  symptoms  are 
headache,  a  feeling  of  oppression,  shortness  of  breath,  and 
great  weakness.  The  most  im])ortant  objective  symptoms 
are  cyanosis,  involvement  of  the  pleura  and  lungs,  cardiac 
weakness,  and  cold  extremities.  Death  usually  occurs  in 
two  days  ;  in  five  or  six  days  at  the  latest. 

The  prognosis  is  bad. 

Anthrax  of  the  intestinal  tract  is  characterized  by  a 
sudden  onset,  with  intense  diarrhea,  vomiting,  cyanosis, 
and  collapse.     The  prognosis  is  bad. 

Tetanus  (lockjaw)  is  caused  by  the  tetanus  bacillus, 
wdiich  invades  the  body  through  a  wound.  The  bacillus 
is  found  in  the  soil,  in  dust,  in  heaps  of  refuse,  in  manure, 
and  in  dung.  It  may  be  carried  into  the  tissues  by  a 
splinter  of  wood  or  glass  or  may  enter  through  any  wound 
of  the  skin.  The  symptoms  of  tetanus  may  appear 
almost  immediately  after  the  injury,  or  the  incubation 
period  may  last  for  days  or  weeks.  In  one  case  of  my 
own  the  patient,  a  boy  ten  years  of  age,  died  in  from  one 
to  two  hours  after  receiving  the  injury,  with  characteristic 
symptoms  of  tetanus.  He  liad  been  running  barefoot 
over  a  heap  of  refuse,  and  a  small  sliver  of  glass  had  en- 
tered his  sreat  toe. 


86  DISEASES  CAUSED  BY  ACCIDENTS. 

Symptoms. — Tonic  convulsions,  consciousness  being 
retained.  At  the  onset  there  is  pain  around  the  wound, 
and  the  patient  is  restless,  sleepless,  and  anxious.  There 
are  aching  pains  and  rigidity  of  the  muscles  of  the  jaw, 
pharynx,  and  neck,  followed  by  tetanic  muscular  spasms. 
The  drawn  facial  expression  is  characteristic.  Pareses, 
and  even  paralyses,  are  said  to  be  sequels  of  the  disease. 

The  prognosis  is  grave. 

Glanders. — This  disease  may,  under  certain  conditions, 
also  rank  as  an  accident,  as  when  the  specific  bacillus  is 
carried  into  a  wound  by  direct  contact  with  an  infected 
horse  or  ass. 

Acute  glanders  is  fatal.  The  incubation  period  lasts 
from  three  to  eight  days,  and  is  followed  by  symptoms  of 
gastric  disturbances,  pains  in  the  limbs,  and  a  feeling  of 
fatigue,  Avhile  characteristic  nodules,  and  subsequently  sup- 
purating ulcers,  develop  at  the  site  of  infection.  A  rash 
appears  on  the  skin,  and  there  is  a  sanguinopurulent  dis- 
charge from  the  nose  ;  the  fever  increases,  and  death  occurs 
in  from  one  to  three  weeks. 

Chronic  glanders  is  characterized  by  aching  rheumatoid 
pains,  lymphangitis,  swelling  of  the  glands,  ulcerations, 
and  moderate  fever.  There  are  successive  crops  of  ab- 
scesses, first  in  one  part  of  the  body  and  then  in  another. 
The  fever  is  moderate.  The  disease  may  last  for  months, 
or  even  for  years. 

Malignant  edema  is  an  infectious  disease  of  which  the 
specific  bacillus  is  found  in  soil  that  has  been  treated  with 
manure,  in  dirt,  in  dust,  and  in  drainage.  The  disease 
occurs  in  man  in  consequence  of  infection  through  a 
wound.  The  incubation  period  may  be  very  short ;  the 
edema  may  begin  to  appear  at  the  site  of  the  infection  in 
from  twenty-four  to  thirty-six  hours.  It  extends  to  the 
surrounding  tissues  and  leads  to  the  formation  of  foul, 
decomposing  ulcers.  The  fever  rises  and  l)ecomes  very 
high,  and  is  accompanied  by  delirium.  Death  may  occur 
within  a  few  days. 


JNFECTTOUS  DISEASES.  S7 

Tuberculosis. — Tuberculosis  is  the  most  important  of 
all  infectious  diseases,  being  the  cause  of  death  in  more 
than  one-seventh  of  all  cases.  The  agent  of  infection,  the 
tubercle  bacillus,  enters  the  body,  as  a  rule,  through  the 
respiratory  organs,  but  may  enter  it  by  way  of  the  diges- 
tive tract  or  the  skin. 

Unhygienic  dwellings,  overcrowding,  poor  and  insuffi- 
cient food,  all  act  as  predisposing  causes ;  a  hereditary 
tendency  is  also  of  recognized  importance.  The  disease 
is  chiefly  disseminated  by  close  contact  witli  infected  indi- 
viduals. It  is  not  surprising,  therefore,  that  tuberculosis 
is  especially  rife  among  working  people. 

We  find,  in  studying  the  relation  between  traumatism 
and  tuberculosis,  that  an  accident  often  awakens  latent 
tuberculosis  to  local  or  general  activity,  or  hastens  the 
course  of  the  disease  when  it  is  already  fully  developed. 
In  treatino;  accident-cases  in  tubercular  individuals  we 
often  find  the  progress  of  the  case  materially  influenced 
by  the  preexisting  disease,  and  are  obliged  to  modify  both 
treatment  and  prognosis  accordingly.  Since  diseased  tis- 
sues furnish  the  favorite  nidus  for  the  growth  of  tubercle 
bacilli,  it  is  not  surjirising  that  tuberculosis  is  most  liable 
to  develop  as  a  local  process  after  traumatism. 

Tiie  tuberculosis  of  skin  and  joints  has  already  been 
discussed.  In  the  part  devoted  to  special  structures  we 
shall  meet  with  many  illustrations  of  its  development  in 
other  parts  of  the  body. 


PART  II, 


I.  INJURIES  AND  TRAUMATIC    DISEASES  OF  THE 

HEAD. 

Anatom(>phi)siolo(/ic  ConsiitJcrations. — The  strengtli  of  the  skull 
varies  greatly  in  different  imlividnals.  When  the  cranial  Iwnes  are 
thick,  severe  blows  often  cause  no  serious  symptoms.  The  l)ones  may 
be  so  thin,  on  the  other  hand,  that  even  a  slight  contusion  proves  fatal. 
In  general,  we  must  rely  on  the  anatomic  fact  that  tlie  ))ones  of  the 
cranial  vault  are  stronger  than  tliose  at  the  base,  and  that  the  latter 
have  many  points  of  weakness  that  give  way  to  e.xternal  violencte. 

It  is  by  no  means  necessary  that  every  force  acting  on  the  skull 
should  cause  a  fracture  ;  on  the  contrary,  the  skull  is  sufficiently  elas 
tic  to  endure  many  blows  and  concussions  without  injury.  But  when 
the  limits  of  elasticity  are  exceeded,  fracture  results.  Since  the  brain 
is  the  center  of  many  important  vital  functions,  the  question  in  every 
head  injury  at  once  arises  as  to  whether  there  is  a  lesion  of  the  brain 
or  its  membranes.  For  the  understanding  of  many  head-injuries 
it  is  accordingly  of  great  importance  to  be  familiar  with  cerebral 
topography. 

Plate  I  (from  Bardele))en's  "Atlas  fur  topogr.  Anatomic")  gives  a 
very  clear  schematic  representation  of  the  centers  lying  on  the  lateral 
convexity  of  the  lirain.  From  tl)e  physiologic  standfjoint  the  whole 
lateral  convexity  can  be  divided  into  two  regions — an  anterior  and  a 
posterior.  The  division  is  made  by  the  fossa  of  Sylvius,  by  the  poste- 
rior liml)  of  the  Sylvian  fissure,  and  by  the  postc^entral  fissure.  The 
anterior  region  is  known  as  the  motor  region,  since  it  gives  rise  to  the 
pyramidal  tract — the  tract  of  vohintary  movements.  Irritation  of  this 
region  causes  involuntary  contractions  of  the  muscles  of  the  opposite 
side,  or,  if  the  irritation  is  continued,  convulsions  (Jacksonian  e]ii- 
lepsy).  Destruction  of  this  region  causes  crossed  paralysis.  Tims,  for 
example,  should  a  tumor  develop  in  the  upper  extremity  of  both  left 
central  convolutions  at  the  spot  marked  Bein  (leg), — /.  e.,  in  the  leg- 
center, — the  pressure  of  the  tumor  would  act  as  an  irritant  and  would 
cause  involuntary  movements  of  the  right  leg.  Since  the  irritation 
would  also  affect  the  neigli))()ring  centers,  the  muscles  of  the  right  arm 
and  of  the  right  side  of  the  face  would  l)e  successively  thrown  into 
spasm  :  in  other  words,  a,  progressive  Jacksonian  epileptic  attack  would 
result.  If,  later,  as  the  tumor  grew,  the  paralytic  action  exceeded  the 
irritative,  a  progressive  paralysis  of  the  right  leg  would  ensue. 

88 


CEREBRAL  TOPOGRAPHY.  89 

lujuiy  to  the  region  marked  Scliril't  (writing)  causes  a  loss  of  the 
luovemeuts  used  in  writing,  while  the  other  movements  of  the  arm 
are  not  interfered  with.  Similarly,  injury  to  Broca's  region  causes  a 
loss  of  those  finer  movements  of  the  lips,  palate,  larynx,  and  tongue 
that  are  necessary  for  speech,  while  the  coarse  movements  in  these 
muscles  are  retained.  The  center  for  the  coarser  movements  of  the 
lips  is  situated  in  the  region  marked  Mund  (facialis)  (mouth — facial 
uerve)  ;  that  for  the  coarser  movements  of  the  tongue  in  the  region 
marked  Zunge  (tongue).  The  center  for  the  coarser  movements  of 
the  palate  and  larynx  is  prol)ably  behind  the  tongue-center.  The 
motor,  .speecli,  and  wiitnig  centers  are  on  the  left  side  of  the  brain. 
The  function  of  the  corresponding  regions  in  the  left  hemisphere  is  not 
known  with  certaiuty. 

Most  motor  centers  are  connected  with  the  opposite  side  of  the 
body  only.  Tlie  centers  for  the  trunk-muscles  and  eye-muscles  are 
exceptions  to  tiiis,  as  both  of  these  centers  have  connections  for  both 
sides  of  the  body. 

It  is  to  be  especially  emphasized  that  individual  cerebral  centers 
are  not  sharply  defined,  but  overlie  one  another. 

The  sensory  region  of  tlie  convexity  is  divided  into  three  sections  : 

1.  The  region  of  the  muscle-sense,  in  the  superior  parietal  lobule. 
When  this  is  destroyed  on  the  left  side,  the  patient  is  unable,  vith 
closed  eyes,  to  recognize  the  jiositiou  of  passive  movements  in  the 
limbs  of  the  right  side. 

2.  The  visual  area,  situated  posteriorly  to  the  parieto-occipital  fis- 
sure. It  is  probable  that  the  part  of  the  visual  area  situated  on  the 
lateral  convexity  is  e.spccially  concerned  with  visual  memories,  and 
has  nothing  to  do  with  sensations  of  sight.  Destruction  of  this  area 
leads  to  "mind-blindness"  :  /.  e.,  the  patient  .sees  perfectly  well,  ])ut 
is  no  longer  able  to  recognize  objects.  The  "reading"  area  belongs 
to  the  visual  area.  When  destroyed,  the  patient  can  still  see  the 
letters,  but  does  not  recognize  them. 

3.  The  centers  for  hearing,  taste,  and  smell,  in  the  temporal  lol)e. 
Injury  to  the  parts  marked  Hiiren  (hearing),  Schmecken  (taste),  and 
Riechen  (smell)  causes  disturbances  in  hearing,  taste,  and  smell,  most 
marked  on  the  opposite  side.  Injury  to  the  region  marke<l  Sprach- 
verstandniss  (understanding  of  language),  the  so-called  Wernicke 
region,  causes  sensory  aphasia  ;  the  patient  hears  perfectly  well,  but 
understands  nothing  (Ziehen). 

Injuries  and  diseases  of  the  cranial  nerves  give  rise  to  the  follow- 
ing symptoms  : 

Injury  of  the  olfactory  (nerve  of  smell,  not  crossed)  in  its  center 
affects  the  power  of  smell.  (When  smell  is  lost,  examination  for  .syph- 
ilis, polypi,  etc.,  is  imperative.) 

The  optic  nerve  is  a  half-crossed  nerve.  The  left  optic  tract  sup- 
plies the  two  left  halves,  and  the  right  o])tic  tract  supplies  the  two 
right  halvesof  the  retina'.  Inj  tiry  to  the  right  ojitic  tract,  accordingly, 
results  in  lo.ss  of  sight  of  the  right  halves  of  both  eyes. 

The  oculomotorins,  the  motor  nerve  of  the  eyeball,  contains 
uncrossed  fibers,  which  govern  thecontractif)n  of  the  pupil,  and  crossed 
fibers,  such  as  those  for  the  movements  of  the  eyeball  and  the  upper 
eyelid. 


90  DISEASES   CAUSED  BY  ACCIDENTS. 

When  the  nerve  is  injured,  there  result  the  f(»llowing  symptoms  : 

Drooping  of  the  upper  lid  (ptosis),  paralysis  ofaceomuiodation  with 
permanent  fixation  lor  distance,  divergence  outward  and  downward 
with  double  vision,  dilatation  of  the  pupil  (mj^driasis  paralytica),  and 
prominence  of  the  eyeball  through  the  one-sided  action  of  the  superior 
oblique  muscle. 

The  antagonist  to  the  motor  oculi  is  the  sympathetic  nerve.  It 
contains  libers  for  the  dilatation  of  the  pupil.  Irritation  of  this  nerve 
sometimes  causes  symptoms  similar  to  thoseof  third-nerve  palsy.  The 
sympathetic  nerve  also  contains  vasodilator  and  vasoconstrictor  fibers 
and  those  that  govern  the  sweat-glands  of  the  head.  When,  therefore, 
there  is  a  unilateral  pallor  or  flushing  or  sweating  of  the  face,  a  lesion 
in  the  .sympathetic  nerve  must  l)e  thought  of. 

The  trochlear  nerve  (fourth  cranial),  the  nucleus  of  which  lies  in 
the  vicinity  of  the  nucleus  of  the  third  cranial  nerve,  supplies  the  supe- 
rior oblicpie  muscle.  Paralysis  of  this  nerve  causes  slight  upward 
and  inward  squint  and  double  vision.  [For  the  diagnosis  of  this 
affection  exainiuation  of  the  double  images  is  usually  necessary. — Ed.] 
The  abducens  nerve  (sixth  cranial  nerve)  supplies  the  external  rectus 
muscle.  When  this  nerve  is  paralyzed,  there  are  double  vision  and 
internal  strabismus. 

The  trigeminus  (fifth  cranial  nerve)  is,  through  its  extensive  branch- 
ings, a  very  important  nerve.  Injuries  to  the  first  branch  cause  anes- 
thesia of  the  eye,  which  often  results  in  ulceration.  Injuries  to  the 
second  branch,  which  is  especially  rich  in  sensory  fibers,  cause  the 
symptoms  known  under  the  name  of  "  tic  douloureux  "  :  viz.,  twitch- 
ings  of  the  face,  watering  of  the  eye,  increased  nasal  secretion,  severe 
facial  neuralgia,  etc.  Injuries  to  the  third  branch  cause  weakness  in 
the  muscles  of  mastication  and  loss  of  taste  in  the  anterior  two-thirds 
of  the  tongue. 

The  tacial  nerve  (seventh  cranial  nerve)  has  many  anastomoses 
with  the  trigeminus  (fifth).  Irritation  of  the  facial  nerve  causes 
spasm  in  the  facial  mascles  ;  paralysis  causes  the  well-known  picture 
of  facial  palsy.  With  the  face  at  rest  there  is  an  ol)literation  of  the 
nasolabial  fold  on  the  paralyzed  side.  The  patient  is  no  longer  able 
to  inflate  the  cheek,  to  whistle,  or  to  shut  the  eye  on  the  affected  side. 

Facial  palsy  can  be  readily  demonstrated  by  the  electric  current. 
The  two  poles  are  placed  at  the  exit  of  the  nerve,  in  front  of  the  ear, 
one  on  each  side.  The  sound  side  contracts,  while  the  affected  one 
contracts  feebly  or  not  at  all. 

The  auditory  nerve,  when  irritated,  gives  rise  to  sensations  of  hear- 
ing ;  when  injured,  to  partial  or  complete  deafness.  If,  however,  the 
fibers  supplying  the  semicircular  canals  are  affected,  there  result 
dizziness  and  interference  with  the  sense  of  equilibrium. 

The  glossopharyngeal  nerve  is  the  nerve  of  taste  for  the  posterior 
third  of  the  tongue  and  for  the  glossopharyngeal  arch.  It  transmits 
bitter  sensations.  By  its  paralysis  this  variety  of  gustatory  function 
is  lost. 

The  vagus  (pneumogastric  nerve)  is  a  widely  distributed  nerve 
with  many  branches.  It  supplies  the  larynx,  the  pharynx,  the  heart, 
the  lung.s,  the  esophagus,  the  stomach,  the  intestines,  and  the  kidneys. 


CONTUSIONS  OF  THE  HEAD.  91 

Irritation  of  the  superior  laryngeal  branches  of  the  vagus  nerve  causes 
cough  and  laryngeal  spasm.  Paralysis  of  these  l)ranches  leads  to 
foreign  bodj^  pneumonia.  Irritation  of  the  thoracic  poitiou  of  the 
pneumogastric  may — for  example,  in  fracture  of  tlie  ribs  and  resulting 
pleurisy — cause  reflex  cough  and  rapid  pulse.  Irritation  of  the  abdom- 
inal portion  causes  vomiting. 

The  spinal  accessory  nerve  has  two  branches,  the  anterior  of  which 
goes  to  the  pneumogastric  while  the  posterior  supplies  the  sterno- 
mastoid  and  latissinius  dorsi  muscles.  Paraly.sis  of  the  posterior 
branch  causes  a  drawing  of  the  head  to  the  other  side  (torticollis),  and 
interferes  with  the  movements  of  the  shoulder  on  the  affected  side. 

The  hyjwglossal  nerve  is  the  motor  nerve  of  the  tongue.  When 
paralyzed,  movements  of  the  tongue  are  no  longer  possible. 


I.  CONTUSIONS  OF  THE  HEAD. 

The  statements  contained  in  the  following  pages  are  based  on  ob- 
servation of  449  cases  of  injuries  involving  the  head  and  face.  Some 
of  the  cases  were  under  observation  for  a  period  of  twelve  years.  The 
injuries  were  proportioned  as  follows  :  259  cases  of  contusion  or  con- 
tusion wounds,  of  which  107  were  complicated  liy  concussion  of  the 
brain  ;  134  cases  of  fracture  of  the  skull  ;  76  lesions  of  the  face.  Of 
the  259  cases  of  contusion,  about  50%  made  a  perfect  recovery  ;  there- 
fore, no  insurance  was  allowed.  Of  the  remaining  number,  which 
included  the  cases  complicated  by  concussion  of  the  brain  and  those 
occurring  in  elderly  individuals,  the  majority  were  considered  to  be 
entitled  to  an  allowance. 

Slight  contusions  of  tlie  head,  such  as  may  be  caused  by 
kicks,  blows,  or  striking  the  head  in  falling,  are  not,  in 
the  majority  of  cases,  when  healthy  individuals  are  con- 
cerned, to  be  looked  on  as  serious  accidents,  unless  the 
skull  is  injured  or  there  is  concussion  of  tlie  brain.  As  a 
rule,  the  accident  does  not  keep  the  patient  from  working, 
and  no  special  attention  is  paid  to  it ;  many  cases,  in  fact, 
are  not  reported  at  all.  In  consequence  of  the  rich  blood- 
supply  of  the  head,  contusions  usually  lead  to  the  forma- 
tion of  hematomata,  which  vary  in  size  and  appearance 
according  to  their  location.  As  a  rule,  they  call  only  for 
temporary  treatment  or  for  none  at  all.  The  hematoma 
may  be  seated  in  the  scalp  itself,  in  the  subaponeurotic 
layer  (where  it  may  give  rise  to  a  mistaken  diagnosis  of 
fracture),  between  the  pericranium  and  the  bone,  or  be- 
tween   tlie   bone   and  the  dura   mater.     If    not   quickly 


92  DISEASES  CAUSED  BY  ACCIDENTS. 

absorbed,  it  is  liable  to  develop  into  a  cyst  or  an  aneurysm. 
Such  a  cyst  is  open  to  the  possible  danger  of  su])purative 
inflammation,  which  may  be  followed  by  cellulitis.  A 
hematoma  that  is  slowly  absorbed  may,  in  other  cases, 
leave  a  hard,  thickened  area  in  the  scalp  or  under  the 
pericranium,  which  may  be  difficult  to  recognize,  but 
which  is  likely  to  give  rise  to  neuralgic  disturbances. 

Serious  contusions  often  cause  fracture  of  the  skull  or 
concussion  of  the  brain,  with  or  without  definite  symptoms 
of  cerebral  hemorrhage. 

Crushing  of  the  head  is  a  more  serious  accident  than 
the  contusions  just  referred  to,  and  may  be  caused  in  vari- 
ous ways.  The  individual  may  be  run  over,  or  may  be 
caught  between  moving  objects  or  under  a  falliiig  wall  or 
embankment,  etc.  Accidents  of  this  nature  usually  cause 
fracture  of  the  skull  :  often  a  compound  fracture.  It  is  a 
remarkable  fact,  however,  that  the  head  is  sometimes  able 
to  bear  even  severe  crushing  without  fracture  or  apparent 
serious  result  of  any  kind.  Two  cases  of  crushing  of  the 
head  that  were  under  my  observation  may  apjiropriately 
be  cited  here.  Both  were  accompanied  by  concussion  of 
the  brain. 

The  first  case  occurred  in  a  workman  about  forty-five  years  of  age, 
whose  head  was  caught  under  a  falling  elevator.  Secjuel  :  severe 
hysteria.  The  second  case  occurred  in  a  workman,  twenty-four  years 
of  age,  whose  head  was  caught  between  tlie  boom  of  a  deriick  and  the 
ground.     Sequel  :  insanity. 

Cerebral  hemorrlinges  caused  by  contusions  of  the  head 
give  rise  to  symptoms  of  compression  of  the  l)rain,  which 
will  be  referred  to  later  on.  If  not  absorbed,  the  hemor- 
rhagic extravasation  frequently  develops  into  one  of  the 
cysts  or  tumors  before  mentioned.  In  some  cases  these 
give  rise  to  no  sym]>toms  of  importance  for  many  years ; 
according  to  some  observers,  periods  as  long  as  thirty  years 
have  elapsed  before  the  symptoms  of  cerelu'al  tumor  be- 
came evident. 

Wounds  of  the  head  occur  with  comparative  frequency. 


FRACTURES  OF  THE  SKULL.  93 

In  the  building  trades  and  mining  industry  they  are  often 
the  result  of  contusions.  Wounds  of  the  scalp  l)leed  very 
freely  ;  the  hemorrhage  is  best  controlled,  after  thorough 
cleansing  of  the  wound,  by  aseptic  or  antiseptic  dressings 
and  tirm  bandaging. 

Open  wounds  of  the  scalp  are  very  frequently  the  seat 
of  infectious  processes,  which  constitute  a  special  source 
of  danger  in  this  situation  because  of  the  venous  connec- 
tion with  the  diploe  and  the  sinuses  of  the  cranium. 

Of  the  infectious  diseases  that  attack  the  head,  erysipe- 
las is  the  one  with  Avhich  we  most  often  have  to  deal.  It 
is  easy  to  understand  how  infection  occurs  if  we  consider 
the  carelessness  and  uncleanliness  shown  by  working-men 
in  treating  their  Avounds.  Erysipelas  usually  runs  a 
favorable  course,  but  occasionally  it  terminates  fatally. 

Purulent  meningitis  is  another  complication  of  open 
wounds  of  the  scalp.  The  prognosis  is  not  unfavorable 
for  this  disease,  as  a  rule,  although  death  sometimes  occurs 
in  severe  cases. 

If  the  cicatrix  resulting  from  wounds  of  the  scalp  is 
superficial  and  moves  \vith  the  scalp,  it  gives  rise  to  no 
symptoms  whatever.  If  there  are  deep  attachments,  how- 
ev^er,  especially  if  reaching  to  the  bone,  serious  disturb- 
ances may  be  caused.  Compression  of  the  nerve-branches 
leads  to  neuralgia,  or  even  to  epileptiform  convulsions. 
Excision  of  the  scar  has  effected  a  cure  in  a  number  of 
such  cases.  Mental  diseases  have  been  known  to  follow 
the  cicatrization  of  wounds  of  the  scalp  ;  a  decided  pre- 
disposition doubtless  existed  in  all  the  individuals  thus 
affected.  Excision  of  the  scar  is  stated  to  have  effected 
a  cure  in  these  cases  also. 

2.  FRACTURES  OF  THE  SKULL. 

Of  the  114  cases  of  fracture  of  the  skull  serving  as  a  basis  for  this 
sectiou,  there  was  fracture  of  the  vault  in  39  cases  aud  of  the  base  in 
25  cases.  The  results  were  as  follows  :  19  patients  made  a  perfect 
recovery;  of  capacity  for  self-support  14  recovered  20%  or  less;  29 
recovered  more  than  20%;  while  in  50  patients  complete  incapacity 
for  self-support  was  diagnosed.     The  sequels  were  as  follows  :  13  were 


94  DISEASES  CAUSED  BY  ACCIDENTS. 

attacked  by  delirium  tremens  ;  6  became  epileptic  ;  8  became  insane  ; 
a  large  number  were  atTected  by  functional  neuroses.  There  were  4 
deatlis  :  one  ilied  of  paralytic  dementia  ;  two  committed  suicide  ;  one 
succumbed  to  tuberculosis. 

Fractures  of  the  vault  are  always  due  to  direct  violence. 
The  theory  that  the  internal  table  of  the  bone  regularly  gives 
way  first,  and  that  it  may  be  fractured  even  in  cases  in 
which  the  outer  table  escapes,  has  of  late  been  disputed, 
and,  in  my  opinion,  not  on  good  grounds.  It  is  a  fact 
that  the  internal  table  is  more  extensively  fractured  than 
the  external  in  all  cases  in  which  the  violence  is  applied 
to  the  latter.  The  reverse  is  true  also.  If  the  inter- 
nal table  is  first  struck, — when  a  l)ullet  passes  through 
the  skull  in  a  case  of  suicide,  for  instance, — the  point  of 
exit  in  the  external  table  is  larger  than  that  of  entrance 


Fig.  1. 

in  the  internal  table.  If  this  statement  is  correct,  we  are 
justified  in  assuming  that  depressions  of  the  skull  after 
injury  indicate  a  corresponding  convexity  of  the  inner 
surface  of  the  inner  table.  Such  a  deformity  on  the 
internal  table  must  necessarily  affect  the  membranes  of  the 
brain,  and  through  them  the  brain  itself.  Figure  1  (from 
Helferich's  "  Atlas  of  Fractures  and  Dislocations")  de- 
picts the  condition  in  question. 

In  such  a  case  as  this  compression  of  the  part  of  the 
brain  underlying  the  deformity  is  inevitable. 

It  would  be  a  grave  mistake,  however,  to  look  upon 
every  depression  to  be  found  on  the  surface  of  the  skull 
as  a  pathologic  depression,  or  to  consider  that  a  de- 
pression necessarily  has  an  injurious  effect  on  the  brain. 
Apart  from  the  fact  that  we  may  be  misled  by  the  sutures, 
which  sometimes  simulate  a  depression,  it  has  been  shown 


FRACTURES  OF  THE  SKULL. 


95 


by  X-ray  photographs  that  depressions  of  the  skull  are 
more  often  diagnosed  than  is  warranted  by  the  actual 
frequency  of  their  occurrence.  It  is  also  true  that  well- 
marked  de])ressions  occasionally  give  rise  to  no  symptoms 
at  all,  as  illustrated  by  the  following  case  : 


-^o' 


Fig.  2. 


Figure  2  shows  a  depression  of  the  skull,  2  cm.  deep  and  5  cm. 
long,  situated  at  the  upper  part  of  the  occipital  bone.  The  .subject  of 
the  illustration  was  a  man  about  tifty  years  of  age  ;  in  his  twentieth 
year  he  was  struck  on  the  head  by  a  block  of  stone  weighing  3j  kilos, 
which  fell  from  the  fourth  story  of  a  building.  He  was  not  attended 
by  a  physician  and  was  ill  ouly  a  short  time.  He  never  developed 
symptoms  of  any  importance. 

Cases  of  this  nature  are,  however,  to  l)e  regarded  as 
exceptions.  As  a  rule,  depressions  of  the  skull  give  rise 
to  definite  symptoms,  such  as  headache,  dizziness,  paraly- 
sis, epileptic  convulsions,  neurasthenic  disturbances,  etc. 


96  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  2. 

Fig.  1.— Circular  Depression  and  Scar  in  the  Middle  of  the 
Forehead  Following  a  Compound  Fracture.  A  carpenter,  fifty- 
four  years  of  ai^e,  injured  on  the  '20th  of  IMareli,  1889,  by  the  fall  of  a 
block  of  building-stone  from  a  height  of  about  fifty  feet.  He  was  un- 
conscious for  four  days. 

Subsequnit  Symptoms. — Vertigo  and  pain  in  the  scar.  Complete  in- 
capacity for  self-support  U])  to  the  16th  of  June,  1891  ;  from  that  date 
up  to  February  19,  1894,  50%  ;  from  that  date  up  to  tlie  beginning  of 
1896,  20%  ;  from  that  time  on  counted  as  fully  capable  of  self-support, 
as  he  did  not  appear  again  for  examination.     Was  a  heavy  drinker. 

Fig.  2. — Deep  Scar  and  Opening  in  the  Left  Frontal  Bone 
Following  a  Comminuted  Fracture.  A  mason,  thirty-one  years 
of  age,  was  injured  on  the  24th  of  October,  1894,  by  a  IjIow  on  the 
forehead  from  a  hammer  (assault). 

Diagnosis. — Compound  comminuted  fracture  of  the  frontal  bone 
and  severe  concussion  of  the  l)rain.  The  splinters  of  bone  were  re- 
moved in  the  hospital. 

SiprqHoms. — At  first,  dull  headache  ;  later,  dizziness  on  movement 
of  the  head  ;  feeling  of  pressure  in  the  direction  of  the  point  of  frac- 
ture on  lowering  the  head,  which  ]»revented  bending. 

Signs  on  Examinalion. — Decided  ]Milsation,  slight  facial  paralysis 
on  the  right  side,  dilatation  of  the  right  pupil  ;  pulse,  100.  No  ner- 
vous symptoms.    Incapacity  for  self-supjiort  since  June  12,  1895,  80%. 


When  there  is  an  opening  in  the  sknll  due  to  trephin- 
ing, the  pulsation  of  the  arteries  within  the  sknll  ean  be 
felt  externally  ;  vertigo  on  stooping  and  a  feeling  of  [)ush- 
ing  and  pressure  in  the  direction  of  the  opening  are  also 
notable  symptoms.  There  may  be  paralysis  and  hysteric 
and  neurasthenic  symptoms  in  addition. 

The  remaining  sequels  of  fracture  of  the  vanlt  are 
similar  to  those  that  follow  concussion,  contusion,  and 
compression  of  the  brain  and  fracture  of  the  base  of  the 
skull. 

Fractures  of  the  base  of  the  skull  occur  in  the  great 
majority  of  cases  as  continuations  of  fractures  of  the 
vault.  They  are  due  to  indirect  violence,  and  may  be 
caused  by  blows  on  the  head,  by  heavy  objects  falling  on 
the  head,  or  by  falls — striking  on  the  head,  the  buttocks, 
or  even  on  the  chin  or  the  feet.     Accordino;  to  the  law  of 


'lab. 


^' 


Fig.l. 


FuiJi. 


I.ilh .  An.sl  /-.'  RoichhoUl,  AMitchen . 


FRACTURES  OF  THE  SKULL.  97 

Arans,  the  lino  of  f  nicture  runs  by  the  shortest  route  from 
the  point  at  which  the  violence  is  applied  to  the  base  of 
the  skull.  It  is,  therefore,  very  important,  in  obtaining 
the  history  of  the  accident,  carefully  to  note  the  point  of 
external  injury. 

Without  entering  into  a  description  of  the  immediate 
symptoms  of  a  fracture  of  the  skull,  it  will  suffice  to  men- 
tion hemorrhages  from  the  nose,  mouth,  or  ear,  and  hemat- 
emesis  as  symptoms  ]K)inting  to  this  lesion.  The  diagnosis 
becomes  clear  if  at  the  same  time  sym])toms  of  concussion 
of  the  brain  or  of  localized  brain-lesions  make  their 
appearance. 

Fractures  of  the  base  of  the  skull  are  not  necessarily 
accompanied  by  severe  disturbances.  Occasionally,  there 
are  so  few  symptoms  at  first  that  the  lesion  is  overlooked. 

This  foot  is  illustrated  hy  tlie  case  of  a  mason  who.  in  falling  from 
a  scaffold,  fractured  his  left  radius  and  at  the  same  time  injured  his 
head.  There  was,  in  addition,  a  hemorrhage  from  tlie  left  ear.  He 
felt  dazed  for  a  time,  but  attributed  this  to  the  shock  of  his  fall  ;  his 
attention  was  mainly  turned  to  liis  broken  wrist.  Later  on  he  fre- 
quently complained  of  headache.  Examination  revealed  left  facial 
paralysis  and  a  rupture  of  the  left  ear-drum,  with  deafness  on  that 
side. 

The  subjective  symjitoms  that  develop  in  the  course  of 
cases  of  fractures  of  the  base  are  usually  those  common 
to  all  fractures  of  the  skull.  Objective  symptoms  may  be 
mentioned  as  follows :  Facial  asymmetry,  asymmetric 
position  of  the  eyes,  prominence  of  one  eyeball,  etc.;  also 
])aralysis  of  the  cranial  nerves.  AVhile  the  facial  nerve  is 
the  one  most  frequently  affected,  paralysis  of  the  oculo- 
motor nerve  and  of  the  abducens,  olfactory,  and  fourth 
cranial  nerves  is  not  at  all  uncommon.  Paralysis  of  these 
nerves  is  not  necessarily  symptomatic  of  fracture  of  the 
base  ;  however,  it  also  follows  fracture  of  the  vault  com- 
plicated by  concussion  of  the  brain. 

The  great  importance  of  the  question  of  involvement 
of  tlie  brain  in  all  cases  of  injury  to  the  head  warrants  a 
short  discussion  of  the  chief  forms  of  injury  of  the  brain 


98  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  3. 

Fm.  l.—Stone=carrier,Thirty=nine  Years  of  Age,  Fell  Back- 
ward from  a  Scaffold  on  the  i6th  of  January,  1895. 

/.'/V/^'Ho.s/s.  — Com  pound  fracture  ol'tho  skull  (t'roiitiil  bone),  fraoture 
of  the  nasal  bone,  of  the  right  malar  bone,  and  of  the  right  side  of  the 
inferior  maxilla,  with  concussion  of  the  brain. 

The  j)atieut  was  treated  for  thirteen  weeks  in  the  hospital  ;  tlien 
attended  the  clinic  until  July  20,  1896.  On  that  day  he  committed 
suicide  by  hanging. 

Symptoms. — Severe  headache  ;  l)uzzing  in  the  head;  feeling  of  im- 
pending danger  ;  dizziness  on  stooping  even  slightly  ;  flashing  of  light 
before  the  eyes  ;  dancing  of  letteis  before  the  eyes  on  reading  ;  tooth- 
ache, especially  during  mastication.  In  the  illustration  the  patient 
w^ears  an  expression  of  melancholy.  A  shallow  depression  is  noticeable 
on  the  leftside  of  the  tbreliead,  or,  rather,  on  the  temple.  The  right 
eye,  the  i)upil  of  which  is  dilated,  has  a  somewhat  fixed  gaze;  the 
angle  of  the  right  inferior  maxilla  is  distinctly  thickened.  The  light 
eyebrow  is  higher  than  the  left.  The  right  na.solabial  ibid  has  disap- 
peared. The  scars  on  the  right  side  of  the  forehead  and  nose  are  still 
red. 

Fig.  2. — Case  of  Left  Facial  Paralysis  with  Atrophy  of  the 
Left  Side  of  the  Face  Following  Fracture  of  the  Base  of  the 
Skull.  The  face  is  somewhat  asymmetric  and  the  leit  eyeball  is 
sligthly  prominent. 

A  painter,  twenty-live  years  of  age,  fell  from  a  ladder  on  the 
18th  of  June,  1889,  at  a  height  of  a1)out  twenty-one  feet,  striking 
on  the  back  of  his  head.  For  six  days  he  was  unconscious,  and  was 
treated  in  the  hospital  lor  eight  weeks.  For  the  first  sixty  liours 
there  was  a  hemorrhage  from  the  left  nostril  and  the  left  ear,  and 
exojjhthalmos  on  the  left  side.  After  consciousness  returned  a  strong 
tendency  to  somnolence  persisted.  After  leaving  the  hospital  the 
patient  was  treated  V)y  massage  and  faradization  of  the  left  side  of  the 
face,  as  a  result  of  which  the  exophthalmos  and  facial  paralysis  were 
much  improved.  The  left  eye  could  be  closed  at  the  end  of  three 
months. 

Remote  Sympioms. — Objective:  Facial  asymmetry,  atrophy  of  the  left 
side  of  the  face,  slight  left  exophthalmos.  Constant  sjjasmodic  con- 
tractions of  the  muscles  of  the  left  side  of  the  face  ;  cicatrix  in  the 
left  ear-drum.  Subjeefive:  Headache,  sudden  attacks  of  vertigo,  espe- 
cially l)rought  on  by  the  entrance  of  foreign  bodies  into  the  left  eye, 
and  accomi)anied  by  the  tendency  to  throw  the  head  downward 
and  to  the  right  ;  buzzing  and  ringing  in  the  head  and  deafness.  Later 
developments  were:  Unsteadine.ssof  gait  in  the  dark  when  in  a  strange 
place  ;  inability  to  lie  on  the  left  ear  ;  increase  of  l)nzzing  in  the 
head  ;  disturbed  sleep  ;  and  frequent  attacks  of  conjunctivitis.  Other- 
wise, the  general  health  was  good.  Inca]iacity  for  self  supjiort  during 
time  of  treatment  was  reckoned  at  \0()'/r  ;  five  months  after  the  acci- 
dent, at  45%  ;  and  later  on,  after  resuming  his  trade,  at  20%. 


Tab.:i. 


riffl  ■ 


'•'.'/•' 


Lith.  An.1t  E  Reichtwld.  Aftinchen . 


I 


FRACTURES   OF   THE  SKULL.  99 

observed  in  conneetion  with  fractures.  They  are  three  in 
nuniher :  Concussion  of  the  brain  (commotio  cerebri), 
compression  of  the  brain,  and  contusion  of  the  brain. 

I .  Concussion  of  the  brain  (commotio  cerebri)  occurs 
as  one  of  the  most  prominent  symptoms  of  fracture  of  the 
skull  as  well  as  of  simple  coniusions  of  the  head.  For 
a  description  of  the  immediate  symptoms  of  concussion 
reference  should  be  made  to  text-books  of  surgery.  Of  these 
symptoms,  unconsciousness  is  one  of  the  most  important, 
implying,  as  it  does,  involvement  of  the  cerebral  cortex. 
It  is  accompanied  by  disturl)ances  of  respiration  and  of 
cardiac  action,  due  to  involvement  of  the  medulla  ob- 
longata. The  face  is  pale,  the  ])upils  scarcely  react  at  all ; 
the  pulse  is  slow  and  is  so  small  and  thready  as  to  be 
hardly  perceptible.  This  condition  is  soon  relieved  in 
mild  cases,  but  in  severe  cases  it  persists  for  some  time, 
and  is  further  accompanied  by  vomiting  and  by  involun- 
tary passage  of  urine  and  feces. 

Loss  of  memory  (anniesia)  is,  in  some  cases,  one  of  the 
most  characteristic  and  important  symptoms  of  the  later 
stages  of  the  disorder.  Patients  thus  affected  are  likely 
to  be  unable  to  recall  the  occurrences  immediately  preced- 
ing the  accident.  Many  patients,  on  the  other  hand, 
complain  only  of  weakness  of  memory  ;  they  are  unable 
to  remember  orders,  especially  if  somewhat  complicated. 
Other  subjective  symptoms  are  :  headache,  vertigo  (most 
marked  on  stooping,  bending  forward,  or  looking  u})ward), 
insomnia,  restlessness,  etc.  As  objective  sym])toms  loss 
or  weakness  of  memory,  attacks  of  dizziness  (Romberg's 
sign),  symptoms  of  functional  neurosis,  and  even  paralysis 
of  cranial  or  peripheral  nerves  may  occur. 

Simulation  is  ()ft(>n  attempted  after  concussion  of  the 
brain,  as,  indeed,  after  all  kinds  of  injury  to  the  head, 
even  of  the  simplest  nature.  It  is  often  very  difficult  to 
distinguish  between  simulation  and  the  unconscious  ten- 
dency toward  exaggeration  characteristic  of  neurasthenic 
and  hysteric  patients. 


100  DISEASES  CAUSED  BY  ACCIDENTS. 

Epilepsy  occasionally  occurs  as  a  sequel  to  concussion 
of  the  brain — usually,  it  is  true,  in  individuals  in  whom 
a  strong  hereditary  nervous  predisposition  exists.  It  also 
occurs  in  alcoholic  sulijects  and  in  tliose  who  previously 
have  suffered  from  syphilis.  Of  my  449  cases  of  injury 
to  the  head,  G  were  followed  by  epilepsy.  (For  furtlier 
reference  to  epilepsy  see  p.  114.) 

Mental  diseases  must  also  be  included  among;  tlie 
sequels  of  concussion  of  the  brain  ;  they  may  be  mani- 
fested immediately  after  the  accident  (primary  traumatic 
insanity)  or,  more  frequently,  in  a  later  stage  of  the  lesion. 
According  to  Stolper's  observations,  mental  diseases 
occurred  twelve  times  in  a  total  of  981  injuries  to  the 
head,  or  in  1.'22  ^  of  the  cases.  The  percentage  in  my 
own  group  of  cases  is  exactly  the  same.  Mental  disease, 
liowever,  may  develop  in  consequence  of  injuries  otiier 
than  those  involving  the  head.  It  may  follow  pcri|)heral 
injury,  or,  more  especially  in  predisposed  individuals,  in- 
sanity may  be  the  outcome  of  intense  and  long-continued 
excitement  or  of  severe  and  constant  neuralgic  pain. 

2.  Compression  of  the  brain  may  be  caused  by  cere- 
])ral  hemorrhage,  usually  due  to  laceration  of  the  middle 
meningeal  artery  ;  or,  less  frequently,  it  may  be  the  result 
of  pressure  from  a  fractured  bone.  Compression  often 
occurs  in  combination  with  concussion.  In  respect  to 
symptoms,  a  slow  pulse,  due  to  irritation  of  the  pneumo- 
gastric  nerve,  is  especially  characteristic.  In  addition, 
the  face  is  flushed, — in  contradistinction  to  the  pallor  seen 
in  cases  of  concussion, — the  eyes  are  bright,  and  the  pupils 
contracted.  The  patient  is  conscious  and  restless  at 
first ;  this  condition  is  followed  by  one  of  depression. 
The  patient  l)ecomes  unconscious,  with  ra})id  pulse,  dilated 
pupils,  and  irregular  respiration.  There  may  be  paralysis 
and  invohmtary  passage  of  urine  and  feces.  In  fatal  cases 
death  soon  ensues  ;  otherwise  the  symptoms  begin  to  abate 
in  severitv.  Tlie  secjuels  are  in  part  similar  to  those  of 
concussion  of  the  brain  ;  in  part  they  are  dependent  on 
the  manner  of  absorption  of  tlie  hemorrhage. 


FRACTURES  OF  THE  SKULL.  101 

Compression  due  to  depressed  fracture  is  occasioually 
followed  by  cortical  epilepsy,  as  shown  by  the  folloAving 
case  : 

A  workman,  thirty-two  years  of  age,  was  caught  under  a  falling 
wall,  and  sufl'ered,  among  other  injuries,  a  fracture  of  the  occipital 
hone.  After  healing  a  deep  depression  was  left  in  the  bone,  which 
was  much  thickened  at  the  point  of  fracture.  About  eighteen 
months  later  the  patient  developed  epileptic  attacks  and  mental  dis- 
turbances. He  is  often  obliged  to  enter  an  insane  asylum  for  treat- 
ment. 

3.  Contusion  of  the  brain  may  be  caused  by  a  sudden 
depression  of  the  bone,  which  may  resiune  its  normal 
shape  immediately  after  the  injury,  or  by  the  penetration 
of  a  splinter  of  bone  into  the  l)rain-substance  in  cases  of 
fracture.  Since  the  lesions  thus  caused  are  in  alrao.st  all 
cases  distinctly  localized  and  limited,  the  symptoms,  of 
course,  correspond,  being  characteristic  of  cortical  lesions 
entailing  a  loss  of  certain  specific  functions.  (Compare 
Plate  1,  with  remarks.) 

The  subjective  symptoms  to  be  observed  in  the  later 
stages  of  the  affection  are  similar  to  those  of  concussion 
of  the  brain  and  of  functional  neuroses — headache,  ver- 
tigo, weakness  of  memory,  etc.  The  objective  symptoms, 
also,  may  resemble  those  of  the  functional  neuroses  or 
those  due  to  diseases  of  the  brain  involving  anatomic 
changes  in  the  latter. 

The  lesions  of  the  cerebellum  deserve  special  consider- 
ation ;  of  the  symptoms  to  which  they  give  rise  ataxia  is 
the  mo.st  prominent. 

Thiem  mentions  the  following  symptoms  :  (1)  Occipital 
|)ain,  with  stillness  of  the  neck.  (2)  Vertigo ;  unsteady 
juovements  in  arising.      ('>)  Xausea  and  vomiting. 

Among  other  sequels  of  injury  to  the  brain,  two  call  for 
discussion  here  :  (1)  Diabetes,  (2)  apoplexy. 

Diabetes  may  follow  injuries  to  the  head  as  well  as 
mental  excitement  or  severe  physical  shock  (as  in  railway 
accidents,  for  instance). 

The  symptoms  are  loss  of  flesh,  furuneulosis,  sexual  im- 


102  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  4. 

Fig.  1. — Case    of    Severe  Comminuted     Fracture    of    the 

Skull.  Extuiiinatioii  reveals  ptosis  ami  iutenial  stial)isnius.  The 
patient  is  markedly  delicieut  iu  intelligence  ;  shows  criminal  tenden- 
cies ;  has  been  imprisoned  a  number  of  times.  The  stupid  expression 
of  tlie  face  is  very  apparent. 

Fig.  1  a. — Showing  Cicatrix  of  Figure  i.  The  pulsation  of  the 
vessels  is  clearly  percei)tible  through  the  opening  in  the  Ijoue. 

A  workman,  twenty-three  years  of  age,  was  injured  by  being 
struck  on  the  liead  by  a  piece  of  iron.  Was  in  hospital  for  two 
mouths.  Began  to  work  in  three  months,  but  was  compelled  to  stop 
on  account  of  headache.     Entered  hospital  again  and  was  trephined. 

Later  Symptoms. — Headache,  vertigo,  frequent  spasmodic  contrac- 
tions of  the  muscles  of  the  calf,  epileptic  convulsions.  On  stoopiug, 
feels  pain,  running  froui  the  back  of  the  head  to  the  foi'ehead. 
Memory  is  weal^. 

Fig.  2.— Cicatrix,  with  Long  and  Rather  Deep  Depression 
in  the  Bone,  Located  on  the  Left  Side  of  the  Skull.  The  cicat- 
rix commences  at  about  the  upper  angle  of  tlie  occipital  bone. 

A.  M.,  stone-carrier,  thirty -three  years  of  age,  was  struck  ou  the 
head  on  the  13th  of  April,  1887,  by  a  building-.stoue  that  fell  from  the 
fourth  story.  The  lesion  was  a  compound  fracture  of  the  skull  caus- 
ing paralysis  of  ))oth  the  upper  and  lower  right  extremities.  After 
removal  of  a  piece  of  the  l)Oue  the  i)aralysis  was  relieved,  except  as  to 
the  fourth  and  fifth  lingers,  in  which  muscular  weakness  and  a  feeling 
of  numbness  persisted  for  a  considerable  period.  A  slight  weakness 
also  remained  in  tlie  foot.  The  patient  was  a  heavy  drinker.  At  first 
his  incapacity  for  self-support  was  reckoned  at  100%  ;  on  the  18th  of 
November,  1888,  it  was  \V.i\//c  ;  ou  the  29th  of  December,  1889,  his 
capacity  for  self-support  was  fully  reestablished.  About  one  year 
later  epilepsy  developed,  accompanied  by  mental  disturljances.  Fre- 
quent institutional  treatment  was  necessitated.     Incapacity,  100%. 

potence,  etc.  The  symptoms  do  not  differ  in  the  least 
from  those  of  diabetes  of  nontraumatic  origin. 

Apoplexy  may  be  directly  caused  by  traumatism  of  the 
head,  esi)ecially  when  there  is  concussion  of  the  brain. 
In  the  great  majority  of  cases,  however,  apo])lexy  can  not 
rank  as  an  accident.  The  individual  attacked  by  apoplexy 
falls  suddenly,  and  in  so  doing  suffers  an  injury  of  the 
head  on  account  of  which  insurance  can  be  recovered. 
Such  an  injury  may  make  it  very  difficult  to  decide 
whether  the  apoplexy  is  the  result  of  the  foil  or  vice 
versa. 


Tab  A. 


Fuj.1 


FajP 


Fig.  2. 


]jll,     in.!  !■■  Ri'iilihohl    Miuirlirn 


THE  BRAIN  AND  ITS  MENINGES.  103 

The  treatment  of  injuries  of  the  head  must  necessarily 
l)e  syniptoniatic.  Psychoses  demand  general  treatment  ; 
drugs  will  nevertheless  be  tmjuently  found  necessary. 
For  headache  the  bromids,  antipyrin,  phenacetin,  and  sali- 
cylic acid  can  be  employed  ;  for  neuralgic  pain,  niorphin  ; 
for  insomnia,  sulphonal  will  prove  useful,  etc.  Galvaniza- 
tion of  the  head  (anode,  one  or  two  milHamperes,  for  about 
one  minute)  or  the  use  of  static  electricity  is  often  followed 
by  good  results.  The  same  may  be  said  of  hydrotherapy. 
Medicomechanical  exercises  have  an  excellent  effect  on 
digestion,  sleep,  mental  condition,  and  the  general  health. 
A  stay  in  the  country  is  very  beneficial.  It  is  advisable 
to  settle  the  matter  of  insurance-rate  as  soon  as  possible. 

The  length  of  time  required  for  after-treatment  de- 
pends largely  on  the  age  of  the  patient  ;  as  a  rule,  young 
})ers(Mis  recover  much  sooner  than  older  patients.  As  far 
as  my  own  cases  are  concerned,  the  younger  individuals 
were  able  to  return  to  work  in  from  four  to  six  weeks, 
while  at  least  as  many  months  were  required  for  elderly 
patients.  It  is  also  a  fact  that  elderly  patients  are  very 
unwilling  to  resume  work,  and  some  never  do  so  at  all, 
while  young  people  usually  take  up  their  trade  again  very 
soon. 

3.  TRAUMATIC  DISEASES  OF  THE  BRAIN  AND  ITS 
MENINGES. 

Inflammation  of  the  Dura  Mater;  Pachymenin- 
gitis.— The  lesion  in  pachymeningitis  consists  of  a  mem- 
branous thickening  of  the  dura.  This  thickening  is  liable 
to  be  the  seat  of  interstitial  hemorrhages  ;  it  may  involve 
either  the  external  or  the  internal  surface  of  the  dura.  It 
is  stated  that  pachymeningitis  is  the  form  more  frequently 
observed  ;  both  forms  occur  usually  in  connection  with 
other  diseases  of  the  brain  and  its  meninges,  rather  than 
as  separate  diseases.  Pachymeningitis  may  be  caused  by 
traumatism — by  contusions  or  fractures  of  the  skull,  for 
-instance — complicated  by  hemorrhagic  extravasation  be- 


104  DISEASES  CAUSED  BY  ACCIDENTS. 

tween  the  bone  and  the  dura  or  between  the  two  layers  of 
the  dura  itself.  Pachymeningitis  is  often  observed  as  an 
accompaniment  of  paralytic  dementia,  but  the  cause  most 
frequently  underlying  the  disease  is  chronic  alcoholism. 

The  symptoms  are  apt  to  be  overshadowed  by  those 
of  the  disease  of  the  brain  with  which  the  pachymenin- 
gitis is  connected.  They  consist  of  headache,  vertigo, 
unilateral  epileptic  spasms,  paralyses,  optic  neuritis,  and 
fever.  In  chronic  cases  the  chief  symptoms  are  contin- 
uous dull  headache,  vertigo,  and  mental  dej^ression. 

The  treatment  is  symptomatic  ;  ice-bags,  blood-letting, 
and  the  use  of  bromids  may  be  mentioned. 

Incapacity  for  self-support,  from  50  to  100^. 

Illustrative  Case. — A  stone-carrier,  forty-five  years  of  age,  fell  from 
a  ladder  on  July  20,  1888,  striking  his  head  against  an  iron  heam. 
Lesion  :  compound  fracture  of  the  frontal  bone.  On  October  16,  1888, 
I  made  an  examination  and  found  the  cicatrix  attached  to  the  frontal 
bone.  The  patient  complained  of  severe  headache  and  of  dizziness. 
In  view  of  the  fact  that  he  was  a  subject  of  chronic  alcoholism,  I  made 
a  diagnosis  of  pachymeningitis.  His  incapacity  for  self-support  was 
50%.' 

4.  TRAUMATIC  INFLAMMATIONS  OF  THE  PIA   MATER. 

Leptomeningitis. — Leptomeningitis  usually  takes  the 
form  of  a  diffuse  sii})})urative  inflauimation,  following  in- 
fection through  the  wound  of  a  com])oimd  fracture,  or 
excited  by  extension  from  an  erysipelas  of  the  scalp  of 
traumatic  origin. 

Symptoms. — Headache,  partial  loss  of  consciousness, 
delirium,  somnolence,  vertigo,  hyperesthesia,  vomiting, 
fever,  rigidity  of  the  muscles  of  the  neck,  disorders  of  the 
cranial  nerves  (o]>tic  and  facial  nerves),  loss  of  pupil- 
lary reflex,  inequality  of  the  jnipils,  ptosis,  and  strabismus. 

Tubercular  basilar  meningitis  of  metastatic  origin 
may  also  develop  after  traumatism  of  the  head.  Its 
symptoms  are  headache,  vomiting,  delirium,  convulsions, 
fever,  somnolence,  rigidity  of  the  muscles  of  the  neck, 
aphasia,  and  paralyses. 


I 


TUMOR   OF  THE  BRAIN.  105 

Hemorrhage  of  the  brain  is  caused  by  the  rupture  of 
a  cerebral  artery  ;  the  middle  cerebral  artery  is  the  one 
most  subject  to  this  accident.  As  a  rule,  rupture  occurs 
in  arteries  affected  by  arterial  sclerosis  or  at  the  seat  of  a 
small  aneurysm.  Cerebral  hemorrhage  is,  therefore,  most 
frequently  observed  in  cases  of  chronic  alcoholism  or 
chronic  lead-poisoning.      (Compare  with  a[)oplexy.) 

Causes. — Severe  muscular  strain,  mental  excitement, 
fright,   acute    alcoholism,    and,   occasionally,   traumatism. 

The  symptoms  are  similar  to  those  of  apoplexy. 

5.  ABSCESS  OF  THE  BRAIN. 

This  lesion  may  follow  an  injury  to  the  skull  or  it  may 
be  secondary  to  another  infectious  process,  such  as  puru- 
lent meningitis,  caries,  etc.  The  abscess  may  be  located 
directly  under  the  injured  spot,  forming  a  superficial  corti-' 
cal  abscess,  or  the  pus  may  become  encapsulated,  causing 
no  symptoms  for  many  years.  Even  ten  or  twenty  years 
may  elapse,  and  the  injury  may  be  quite  forgotten,  when 
suddenly  there  is  a  violent  outbreak. 

[It  should  not  be  forgotten  that  cerel)ral  abscess  may  be 
the  direct  result  of  scalp  wounds  that  had  been  regarded 
as  insignificant  or  had  been  overlooked  altogether.  It 
frequently  follows  pistol-shot  wounds. — Ed.] 

Symptoms. — Localized  cortical  symptoms,  paralyses, 
dull  headache,  vomiting,  vertigo,  fever,  convidsions,   etc. 

6.  TUMOR  OF  THE  BRAIN. 

Tumors  of  the  brain,  originating  in  the  bone,  meninges, 
blood-vessels,  or  substance  of  the  brain  itself,  may  develop 
in  consequence  of  traumatism  ;  gliomata,  gummata,  and 
sarcomata  are  the  varieties  most  frequently  observed. 
The  growth  of  a  glioma  may  cover  a  period  of  many 
years — in  one  case  on  record  a  period  of  thirty  years,  dat- 
ing from  the  time  of  accident.  (See  Adler,  "  Arch.  f. 
Unfiillheilk.,"  vol.  n,  1898.) 


106  DISEASES  CAUSED  BY  ACCIDENTS. 

[The  relationship  between  traumatism  and  the  develop- 
ment of  tumors  in  the  nervous  system  is  so  difficult  of 
demonstration  that  unless  the  time-interval  between  the 
receipt  of  the  injury  and  the  first  a})pearanre  of  symptoms 
is  reasonably  short,  the  causal  connection  between  the  two 
is  little  more  than  conjectural. — Ed.] 

Symptoms. — Headache,  central  vomiting-,  vertigo, 
dullness,  somnolence,  slow  pulse,  a])oplectiform  and  epilep- 
tiform attacks,  optic  neuritis,  and  focal  symptoms.  The 
localized  symptoms  vary  with  the  site  of  the  tumor. 

Treatment. — Symptomatic  ;  possibly  trephining  and 
removal  of  the  tumor. 


7.  PROGRESSIVE  PARALYSIS,  DEMENTIA  PARALYTICA. 

Traumatism  (injuries  of  the  head,  fractures  of  the 
skull)  may  be  followed  by  a  process  of  degeneration  in 
the  brain,  to  Avhich  the  foregoing  name  has  been  given. 
The  signs  of  cerebral  degeneration  may  become  apparent 
very  soon  after  the  injury  or  not  until  considerably  later. 
Imbecility,  sy])hilis,  and  chronic  alcoholism  all  act  as  ])re- 
disposing  factors.  In  predisposed  individuals  ])aralytic 
dementia  may  also  develop  after  ])eriplieral  injuries  as  the 
sequel  of  a  traumatic  neurosis. 

[The  editor  has  made;  a  study  of  the  reports  of  cases 
of  alleged  traumatic  general  ])aresis  and  of  a  number  of 
])ersonally  ol)served  cases  of  the  disease  in  which  trauma 
figured  prominently  in  the  history  given  by  the  jmtient  or 
his  friends.  ("  Accident  and  Injury:  Their  Relations  to 
Diseases  of  the  Nervous  System."  Bv  Pearce  Bailey, 
M.D.  D.  Appleton  &  Co.,  1898.)  From  this  study  the 
conclusion  seems  unavoidable  that  if  trauma  is  ever  the 
sole  cause  of  general  paresis,  such  a  causal  relationship  is 
extremely  unusual  and  difficult  of  j^roof,  and  is  to  be 
accepted  only  after  scrupulous  in(piiry  has  eliminated  the 
many  opportunities  for  error.  General  paresis  is  a  disease 
characterized  by  an  excitable  and  iuf'tt'^ntive  mental  state 


FUNCTIONAL  NEUROSES.  107 

whicli  exposes  the  victim  to  all  kinds  of  physical  injury, 
so  that  an  injury  that  is  advanced  as  a  cause  may  well  be 
one  of  the  results.  Furthermore,  the  onset  of  the  dis- 
ease is  so  insidious  that  it  is  practically  impossible  to  tell 
when  it  begins.  If  all  these  tacts  are  considered,  few 
physicians  Avould  care  to  go  further,  in  any  given  case, 
than  to  say  that  the  injury  stood  in  a  direct  causal  rela- 
tionship with  the  brain-disease. — Ed.] 

Symptoms. — Changes  in  the  character;  changes  in 
and  dimimition  of  mental  ability,  memory,  and  power  of 
speech  ;  a  tendency  to  excesses  ;  ine<[uality  of  the  pn})ils 
and  loss  of  })upillary  reflex  ;  ])aralytic  disturbances  of 
speech  ;  loss  of  the  patellar  reflex  ;  tremor  of  hands  and 
tongue  ;  ])aralytic  attacks  ;  delusions,  etc. 

Illustrative  Cases. — 1.  A  workman,  foitj'-three  years  of  age,  becani« 
unconscious  after  falling  from  a  ladder,  l)ut  soon  regaiued  conscious- 
ness. He  visited  a  dispensary,  where  lie  received  treatmeut  for  au 
injury  of  the  thumb.  One  year  after  the  injury  he  began  to  sutfer 
from  frequent  attacks  of  lieadache,  increasing  in  severity.  Six  months 
later  he  developed  acute  mania  and  was  placed  iu  an  insane  asylum. 
Diaguosis  :  progress! re  parali/sis. 

2.  A  roofer,  thirty-one  years  of  age,  fell  about  fifteen  feet,  striking 
on  his  feet  and  suftering  a  compound  fracture  of  the  left  ankle. 
Recovery  was  very  j)r()tracted.  Two  years  later  he  consented  to  the 
amputation  of  his  loot.  As  he  Avas  unable  to  pursue  his  trade,  he 
worked  at  odd  jobs.  Four  years  after  the  accident  a  diaguosis  was 
made  of  dementia  ])aralytica.  His  death  occurred  six  years  later. 
The  connection  between  the  accident  and  the  mental  disease  was 
recognized  iu  this  case. 


8.  FUNCTIONAL  NEUROSES. 

Traumatic  Neurosis  (Oppenheim),  Neurasthenia,  Hysteria, 
and  Hypochondriasis. 

Since  the  passage  of  the  laws  relative  to  accident-insur- 
ance,/»?K'^'o//a/  nao'oses  have  been  the  snbject  of  wide- 
spread interest.  The  ]>ul)licati()n  of  the  work  of  Op])en- 
heim  on  "  Traumatic  Neuroses "  was  the  signal  for  the 
expression  of  all  sorts  of  opinions  on  functional  neuroses, 
which,  far  from  casting  light  on  the  subject,  succeeded  in 


108  DISEASES  CAUSED  BY  ACCIDENTS. 

confusing  the  minds  of  inexperienced  physicians,  in  creat- 
ing; dissension  in  trades-unions,  and  in  doing  real  harm  to 
the  sufferers  from  accidents,  who  were  led  to  believe  them-, 
selves  entitled  to  insurance  or  afflicted  \vith  imaginary 
symptoms.  The  belief  that  traumatic  neuroses  were  in- 
curable, and  that  they  led  to  complete  and  permanent 
incapacity  for  self-support,  had  a  very  injurious  effect  on 
all  interested  persons.  The  general  confusion  of  ideas  on 
the  subject  has  been  further  heightened  by  the  mistake, 
committed  by  many  physicians,  of  making  a  diagnosis  of 
traumatic  neurosis  in  cases  not  exhibiting  the  slightest 
sign  of  neurosis,  such  as  internal  organic  diseases  accom- 
panied by  fever  and  delirium,  and  in  various  diseases  in 
which  the  diagnosis  was  questionable.  The  uninitiated 
soon  came  to  believe  that  in  traumatic  neurosis  a  new, 
severe,  and  incurable  nervous  disease  had  been  discovered. 
The  term  "accident-neurosis"  may  have  arisen  in  this 
manner. 

Opj)onlieim  gained  a  large  number  of  adherents  at  first, 
among  them  physicians  of  prominence.  Vigorous  oppo- 
sition was  made,  on  the  contrary,  to  the  acceptance  of  the 
symptom-complex  described  by  him  as  characteristic  of 
traumatic  neuroses.  It  was  said  by  some  of  his  oppo- 
nents, physicians  of  high  standing,  that  this  symptom- 
complex  represented  no  new  disease ;  that  the  symptoms 
he  described  were  those  of  neurasthenia,  hysteria,  or  hy- 
pochondriasis, or  combination-forms  of  these  diseases. 
Further,  that  it  was  both  unnecessary  and  undesirable  to 
invent  a  new  name,  as  it  would  only  give  rise  to  incorrect 
ideas  regarding  the  nature  and  significance  of  functional 
neuroses.  This  point  of  view  has  now  come  to  be  gener- 
ally accepted  as  correct.  Whenever,  therefore,  the  term 
*' traumatic  neurosis"  appears  in  the  text,  it  is  intended 
to  describe  one  of  the  functional  neuroses  known  to  us 
under  the  name  of  neurasthenia,  hysteria,  or  hypochon- 
driasis, which  has  developed  under  the  influence  of  trau- 
matism. 


FUNCTIONAL  NEUROSES.  109 

We  must  hear  dearly  in  mind  the  generally  accepted  defi- 
nition of  functional  neuroses:  namely,  that  they  are 
affections  of  the  nervous  system  not  dependent  upon  any 
demonstrated  anatomic  changes,  but  recognized  by  the  changes 
in  functional  power  by  which  tliey  are  characterized.  Ac- 
cording- to  this  definition,  we  must  exclude  all  diseases  of 
the  nervous  system  that,  by  reason  of  the  nature  of  the 
injury  and  of  the  symptoms  exhibited,  seem  clearly  to  in- 
volve anatomic  chanires  in  the  nervous  tissue. 

[The  terms  "  functional "  and  ''  organic,"  while  indis- 
pensable for  clinical  purposes,  rest  on  an  uncertain  foun- 
dation. Pathologic  inquiry  is  constantly  revealing  a 
material  basis  for  disorders  previously  regarded  as  func- 
tional. It  is  extremely  probable  that,  in  many  of  the 
cases  that  are  put  in  the  rubric  of  "  traumatic  neurosis," 
the  symptoms  following  severe  traumatisms  are  due  to 
such  demonstrable  lesions  in  the  central  nervous  system 
as  capillary  hemorrhages,  small  foci  of  softening,  etc., 
with  their  sequels.  But  until  this  probability  receives 
more  positive  demonstration  than  it  has  as  yet  obtained, 
such  cases  must  continue  to  be  called  ''  functional "  or,  at 
best,  "  unclassified." — Ed.] 

It  is  worthy  of  note,  too,  that  functional  neuroses  do 
not  develop  as  a  result  of  traumatism  except  in  predis- 
posed individuals — suljjects  of  a  nervous  heredity,  alco- 
holism, etc.  For  while  "  strong  natures  are  able  to 
withstand  mental  shock  without  wavering,  weak  natures 
succumb  to  physical  or  psychic  traumatism." 

[This  statement  requires  qualification,  for  in  the  ex- 
perience of  the  editor,  cases  of  severe  functional  nervous 
disturbances  following  fright  or  sliglit  injuries  develop 
when  there  is  absolutely  no  predisposition  demonstrable, 
either  in  the  patient  himself  or  in  his  ancestral  history. 
This  is  true  of  both  hysteria  and 'neurasthenia. — Ed.] 

Working-men  are  exposed  to  the  influence  of  a  number 
of  predisposing  and  accidental  factors  favoral)le  to  the 
development   of  functional   neuroses,   such  as  hereditary 


110  DISEASES  CAUSED  BY  ACCIDENTS. 

teiKlcncio.s  to  nervous  diseases,  alcoholism,  or  epilepsy ; 
inipcrfeet  mental  and  ])liysi('al  development  ;  unsanitary 
housing ;  poor  and  insufficient  food  ;  worry  and  care ; 
alcoholic  excesses,  etc. 

(a)  Neurasthenia. 

[Neurasthenia  induced  by  injury  or  fright  has  an  event- 
ful pathologic  hist(»ry.  It  is  the  "railway  spine"  of 
Erichsen,  the  "  railway  brain  "  of  later  writers,  and  even 
to-day  is  called  by  these  or  similarly  indefinite  terms. 
With  the  exception  of  an  unusual  prominence  of  the  com- 
])laint  of  pain  in  the  back,  and  of  morbid  fevers  referable 
to  the  accident,  its  symptomatology  is  practically  the  same 
as  that  of  neurasthenia  due  to  causes  other  than  injury. 
It  is  a  very  frequent  source  of  litigation  in  personal-injury 
claims  in  this  country.  When  the  symptoms  are  pro- 
nounced and  persistent,  it  is  a  disabling  aft'ection.  In  the 
majority  of  cases,  however,  the  patient  is  eventually  able 
to  resume  his  occupation. — Ed.] 

This  term  designates  a  condition  of  morbid  weakness 
and  irritability  of  the  psychic  and  physical  activities. 
A  neurasthenic  is  able  to  begin  physical  tasks  with 
energy,  but  soon  tires,  and  in  consequence  comes  to  im- 
agine that  he  is  actually  ill. 

The  symptoms  are  as  follows  :  Changes  in  dis})osi- 
tion  ;  irrital)ility  ;  diminution  of  will-power  and  of  power 
of  work  ;  lack  of  power  of  concentration  ;  absent-minded- 
ness ;  fatigue  on  slight  exertion ;  morbid  self-observa- 
tion ;  headache ;  sense  of  ])ressure  in  the  head  ;  tremor  ; 
flashing  before  the  eyes  ;  freiiuent  attacks  of  insomnia  ; 
dreams  of  an  unpleasant  and  exciting  nature  ;  palpitation 
of  the  heart  ;  pains  of  various  kinds  ;  imperative  con- 
ceptions ;  etc. 

Objective  symptoms,  such  as  paresthesias  and  exag- 
gerated  reflexes,  are  often  present,  but  not  necessarily  so. 


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HYSTERIA.  Ill 


(b)  Hypochondriasis. 

In  this  aifection  the  imagination  and  self-observation 
of  the  patient  are  more  concentrated  on  one  special  point. 
While  a  neurasthenic  complains  first  of  one  ailment  and 
then  of  another,  sometimes  feels  better,  sometimes  worse, 
and  desires  to  talk  about  his  condition,  a  hypochondriac 
clings  firmly  to  his  special  form  of  complaint,  and  broods 
over  it  in  silence.  A  belief  in  abdominal  disorders  is 
especially  characteristic  of  hypochondriasis. 

A  Case  of  Traumatic  Neurosis  Following  Fracture  of  the  Skull  and 
Concussion  of  the  Brain. — A  stone-carrier,  thirty-seven  years  of  age, 
was  hit  on  the  head  bj-  a  lon.^  board  that  fell  from  the  second 
story.  Tiie  accident  happened  on  tlie  26th  of  Novenilier,  1888.  He 
was  tirst  treated  by  his  lodge  doctor,  then  in  the  hospital.  He  resumed 
work  for  a  short  period,  but  was  obliged  to  discontinue  it  on  account 
of  headache  and  to  reenter  the  hospital,  where  he  was  treated  for 
abscess  of  the  brain.  I  examined  the  patient  on  the  25th  of  Fel)ruary, 
1889,  and  noted  the  following  symptoms  :  Headache  ;  attacks  of  ver- 
tigo ;  flashing  before  the  eyes  ;  disturbed  sleep  ;  tremor ;  unsteady 
gait,  more  apparent  in  the  house  than  on  the  street.  The  patient 
looked  well  nourished  and  in  good  health.  He  was  afterward  ex- 
amined by  various  alienists,  and  declared  by  some  to  be  guilty  of  sim- 
ulation ;  after  much  etfort,  however,  he  olitaiued  an  allowance  based 
on  50  fo  incapacity  for  self-support. 


(c)  Hysteria. 

[Of  all  diseases  for  which  compensation  is  sought  at 
law,  none  is  subject  to  such  gross  misconception  as  trau- 
matic hysteria.  It  has  a  well-established  and  characteristic 
symptomatology,  yet  it  seldom  is  recognized  by  physicians 
generally  in  this  coimtry.  It  is  essentially  a  mental  dis- 
ease, but  since  its  most  striking  manifestations  arc  physical 
(e.g.,  paralysis,  blindness,  loss  of  sensibility,  contracture, 
etc.),  the  patient  has  the  appearance  of  a  badly  crippled 
man  rather  than  of  a  person  suffering  from  perverted 
psychic  functions.  The  result  is  that  ignorant  or  corrupt 
experts,  and  juries,  formulate  their  opinions  on  the  appear- 
ance of  the  plaintiff,  without  stopping  to  inquire  as  to  the 


112  DISEASES  CAUSED  BY  ACCIDENTS. 

true  nature  of  the  disorder.  As  a  eonsequence,  excessive 
verdicts  are  rendered  the  phiintiff,  on  tlie  hypothesis  that 
the  injuries  are  incurable  and  permanent.  Now,  it  can 
not  be  denied  that  as  a  result  of  improper  treatment  or  of 
unfortunate  environment  traumatic  hysteria  may  become  an 
t^xtremely  rebellious  affection  ;  but  it  should  be  admitted, 
with  equal  candor,  that  the  psychosis  is  essentially  curable 
in  its  nature,  and  that  the  majority  of  the  patients,  with 
time  and  proper  care,  get  well ;  and  that  verdicts  rendered 
on  the  hypothesis  that  the  plaintiff  is  ruined  for  life  are 
unjust  in  the  extreme.  This  subject  deserves  more  atten- 
tion than  it  receives.  The  disease  comes  frequently  to  the 
notice  of  physicians  who  have  to  deal  with  disorders  of 
the  nervous  system  following  accidents,  and  it  is  particu- 
larly liable  to  lead  to  litigation. — Ed.] 

The  term  hysteria  denotes  a  condition  dependent  upon 
morbid  mental  Gonceptions.  If  a  hysteric  patient  dreams, 
for  instance,  that  he  has  l)een  run  over,  he  believes  on 
awakening  that  the  accident  has  really  occurred.  The 
disease  is,  therefore,  of  a  psychic  nature,  the  morbid  con- 
ceptions on  which  it  is  grounded  being  called  forth  by 
suggestion.  These  conceptions  give  rise  to  innumerable 
functional  anomalies,  both  motor  and  sensory,  which  are 
not  based,  so  far  iis  can  be  ascertained,  on  any  organic 
changes.  Hysteric  patients  are  very  susceptible  to  sug- 
gestion and  to  autosuggestion.  New  ideas  and  concep- 
tions are,  therefore,  very  readily  awakened  in  them,  and 
they  are  easily  influenced  by  strangers.  Their  decisions 
are  not  to  be  counted  on  ;  tiieir  attitude  toward  their 
associates  is  capricious  ;  they  are  moody,  irritable,  absent- 
minded,  and  likely  to  act  on  impulse. 

The  physical  symptoms  of  the  disease  may  be  (1)  per- 
man(nit  (stigmata)  or  (2)  ])eriodic  (hysteric  attacks). 

To  the  first  class  belong : 

1.  Hemianesthesia,  complete  loss  of  ordinary  sensation 
of  one  half  of  the  body  ;  possil)ly  also  insensibility  to  pain. 
The  sense  of  taste,  of  smell,  and  of  hearing  may  l)e  abol- 


HYSTERIA.  113 

ished  on  the  affected  side  ;  there  may  be  partial  color-blind- 
ness and  retraction  (jf  the  visual  field. 

i^.  Hypercdhcmi. — This  may  aif'ect  all  of  one  side  of  the 
body  or  only  parts  of  the  same.  Hysteric  attacks  may  be 
brought  on  by  pressure  on  the  hyperesthetic  areas.  Various 
morbid  sensations  also  belong  to  this  class,  such  as  the 
globus  hystericus,  for  instance. 

3.  Hysteric  paralyses,  which  may  disappear  as  suddenly 
as  they  develop. 

4.  Hysteric  Contractures. — Hysteric  couvulsive  attacks  are 
manifestations  of  central  irritation,  exhibiting  the  most 
varying  forms  and  combinations  of  forms.  The  attacks 
consist  of  clonic  and  tonic  spasms  of  the  extremities  and  the 
face,  the  latter  Ix'ing  distorted  by  grimaces,  while  the 
patient  alternately  laughs  and  weeps,  and  assumes  strange 
postures.  Hallucinations  frequently  accompany  the  at- 
tacks. Hysteric  convulsions  differ  from  those  of  true 
epilepsy  in  not  being  accompanied  by  the  deep  coma 
characteristic  of  the  latter  disease.  In  hysteria  conscious- 
ness is  invariably  retained,  and  the  reflexes  are  not 
aflected  ;  the  patients  usually  fall  with  the  least  possible 
injury  to  themselves,  while  epileptics  fall  face  downward. 
Hysteric  patients,  furthermore,  can  be  aroused  from  a 
convulsive  attack  by  gentle  shaking  and  by  sprinkling 
with  cold  water. 

The  treatment  of  hysteria  should  chiefly  be  directed 
toward  the  removal  of  all  influences  calculated  to  encourage 
the  morbid  feelings  of  the  patient.  Work  is  usually  the 
best  therapeutic  agent  for  a  hysteric  or  neurasthenic  work- 
ing-man, and,  for  this  reason,  in  estimating  the  insurance 
allowance  it  is  advisable  to  avoid  a  high  rate,  wdienever 
feasible,  in  order  to  compel  the  patient  to  work.  A  high 
rate  of  insurance  encourages  the  patient  to  believe  himself 
to  be  seriously  ill,  whereas  if  he  is  obliged  to  go  to  work,  his 
morbid  conception  will  be  overcome,  and  his  recovery  will 
ensue.  It  is  characteristic  of  accident-neuroses  that  the 
mind  of  the  patient  is  almost  altogether  occupied  wdth 


114  DISEASES  CA USED  BY  A CCIDENTS. 

questions  relating  to  the  accident  and  all  that  appertains  to 
it,  and  to  the  I'ate  of  insurance  to  be  allowed. 

Epilepsy  not  infrequently  develops  as  a  sequel  of  injuries 
of  the  head,  especially  in  cases  of  depressed  fracture  en- 
tailing irritation  of  the  brahi-cortex  by  reason  of  a  thicken- 
ing of  the  bone,  a  cicatrix  in  the  meninges,  or  an  inflam- 
matory process.  It  is  also  observed  as  a  result  of  the 
cicatrization  of  wounds  of  the  scalp. 

A  typical  epileptic  attack  is  inaugurated  by  an  aura 
(headache,  vertigo,  nausea,  general  discomfort,  etc.).  In 
addition  to  the  convulsions,  which  are  both  clonic  and  tonic 
in  nature,  the  attack  is  characterized  by  the  following 
symptoms  :  unconsciousness,  loss  of  reflexes,  foaming  at 
the  mouth,  biting  the  tongue,  and  clenched  fists.  After  the 
attack  passes  off  the  patient  feels  dazed,  nauseated,  de- 
pressed, and  generally  unwell.  This  condition  may  persist 
for  some  time.  Of  the  attack  itself  the  patient  has  no 
remembrance  whatever. 

Epilepsy  can  in  some  cases  be  cured  by  trephining  and 
by  removing  the  irritating  cause.  Predisposition  plays  no 
less  important  a  part  in  the  etiology  of  this  disease  than  in 
other  nervous  diseases  following  traumatism.  An  alco- 
holic heredity  is  an  especially  strong  predisposing  factor. 
Epileptic  attacks  may  be  brought  on  by  peripheral  injuries 
as  well  as  by  injuries  to  the  head. 

Illustrative  Case. — A  painter,  tweuty-uine  years  of  age,  who  had 
frequently  suflfererl  from  lead-poisonino;,  fell  from  a  height  of  twenty- 
five  feet  on  the  80th  of  April,  1889.  Lesion  :  fracture  of  the  base  of 
the  skull  with  paralysis  of  the  left  arm.  The  patient  was  treated  for 
one  month  in  the  hospital  and  for  another  month  in  the  dispensary. 
He  then  resumed  work.  On  the  4th  of  Septeml)er,  1889,  he  was 
again  examined  with  reference  to  insurance,  because  of  headache  and 
dizziness.  On  the  11th  of  November,  1889,  he  felt  entirely  well,  and 
resumed  work.  He  was  then  considered  to  be  ftiUi/  capable  of  self- 
support.  On  the  16th  of  March,  1895,  he  sufered  an  epileptic  attack, 
which  was  repeated  at  intervals.  The  connection  between  the  accident 
and  the  epilepsy  was  proved,  and  he  was  allowed  100%  insurance. 


INJURIES  OF  THE  FACE. 


115 


Injuries  of  the  Face. 

Slight  contusions  of  the  face  heal  without  difficulty,  unless 
they  occur  in  connection  with  concussion  of  the  brain  or 
injuries  to  the  nerves.  They  do  not  hinder  the  patient 
from  working,  or  do  so  for  a  very  short  time,  and  they  are 
often  not  reported  at  all. 

Severe  contusions,  on  the  other  hand,  are  likely  to  be 
associated  with  fractures  or  with  concussion  of  the  brain. 


Fig.  3. 

Figure  3  shows  a  workman,  thirty-seven  years  of  age,  who  suffered 
a  contusion  of  the  right  cheek,  as  a  result  of  a  blow  from  the  haudle  of 
a  wheelbarrow  that  was  overturned.  The  accident  occurred  on  July 
17,  1887.  The  patient  developed  a  typical  case  of  traumatic  neurosis, 
according  to  Oppenheim  ;  and  I  have,  therefore,  tried  to  show  his 
facial  expression  in  a  photograph.  INIental  depression  was  a  very 
prominent  feature  of  the  case.  This  patient  was  by  many  observers 
considered  to  be  guilty  of  simulation,  and  the  medical  faculty  of  the 
Berlin  University  wrote  an  opinion  on  his  case  in  1891.  This  opinion 
can  be  found  in  the  "  Aerztl.  Vereinsblatt,"  and  also  in  the  "A.  N. 
d.  R.-V.-A."  of  the  first  of  October,  1897,  (Compare  with  Traumatic 
Neuroses.) 


116  DISEASES   CA USED  BY  A CCl DENTS. 


PLATE  5. 

Fig.  1. — Adherent  Scar  Over  the  Left  Malar  Bone,  Fonow= 
ing  Contusion  and  a  Probable  Fracture.  Tlie  siiir  is  very  ap- 
parent in  the  picture,  as  is  also  a  tliickening  of  the  iiiahir  l)one  and  a 
conjunctivitis,  wliich  is  more  marked  on  the  lel't  side.  '  The  left  eye  is 
seen  to  be  watering.  The  patient  was  a  workman,  {'orty-nine  years  of 
age,  who  was  struck  on  the  left  cheek  by  a  board  that  fell  from  a  height 
of  about  fifty  feet. 

St/mjitoms.- — Pain  on  the  left  side  of  the  iace  ;  headache  ;  dizziness  ; 
toothache,  especially  during  nuisticatiou  ;  loss  of  the  sense  of  smell 
on  the  left  side  of  the  nose.  In  examining  the  patient  the  constant 
lacrimation  and  a  loud  snuttling  were  very  noticeable  points. 

Diagnosis. — Neuralgia  of  the  left  infra-orbital  nerve.  From  mas- 
sage the  best  results  were  obtained.  Division  of  the  nerve  and  loosen- 
ing of  the  scar  gave  no  relief.  For  two  years  the  incai)acity  for  self- 
support  was  reckoned  at  50%  ;  one  year  later,  complete  incapacity. 

FitiiRK  2  Represents  the  Narrow  Entrance  of  the  Right 
Nostril  in  the  Case  of  Compound  Fracture  of  the  Nasal  Bones 
Referred  to  in  Connection  with  and  illustrated  by  Figure  4. 
The  patient  conij)]ained  ol'  dithculty  in  breathing,  and  was  obliged  for 
a  long  time  to  breathe  through  his  mouth.  Later  on,  the  difficulty 
gradually  disappeared.  The  ])ictuie  was  taken  six  years  after  the 
accident.  He  was  receiving  10%  allowance  ;  about  eighteen  months 
later  he  fully  recovered  bis  capacity  ibr  self-support. 


Wounds  of  the  face  are  of  greater  iiii])()rtaii('e,  partly 
because  they  are  especially  subject  to  infection  by  ery- 
sipelas, partly  because  of  the  rich  nerve-suj)ply  of  the 
face  and  of  the  clanger  of  injury  to  the  same.  Deep 
wounds  may  involve  the  facial  or  trigeminal  nerve,  and  so 
give  rise  to  neuralgia  or  })aralysis.  Deep  cicatrices  may 
press  on  underlying  nerve-branches,  causing  painful  spasms 
of  the  facial  muscles  and  involuntary  lacrimation.  Injury 
to  the  ophthalmic  branch  of  the  facial  nerve  causes  lagoph- 
thalmos  (im])erfcct  closure  of  the  lids),  as  a  result  of 
which  the  eye  is  exposed  to  the  danger  of  the  entrance  of 
foreign  bodies. 

Burns  of  the  face  caused  by  boiling  water,  freshly 
slaked  lime,  explosions  of  spirit  or  kerosene  lamps  or  of 
gas-})ipes,  etc.,  are  likely  to  lead  to  extensive  cicdfricidl 
growth  and  consequently   to  facial  deformities,  which    in 


Tab.  .7. 


Tig.l. 


:^' 


Ful  ^. 


Lith.  Anst  F.  Reichhold.  Aliiiirheii . 


A  Text-Book  of  DISEASES  of  WOMEN. 

By  Charles  B.  Penrose,  M.D.,  Ph.D., 
Professor  of  Gyne- 
cologfy  in  the  Uni- 
versity of  Pennsyl- 
vania;   Surgeon  to 


PENROSE'S 
DISEASES 
OF  WOMEN 


the  Gynecean  Hospital,  Philadelphia. 
Octavo.  531  pages,  handsomely  illus- 
trated.   Cloth,  $3.75  net.     J-     ^     ^ 

THIRD  EDITION,  REVISED. 

In  this  work,  which  has  been  written  for  both 
the  student  of  gynecology  and  the  general  prac- 
titioner, the  author  presents  the  best  teaching 


"  I  shall  value  very  highly  the  copy  of  Penrose's 
'  Diseases  of  Women  '  received.  1  have  already 
recomnieiided  it  to  my  class  as  THE  BEST 
book." — Howard  A.  Kelly,  Professor  of  Gyve- 
cology  and  Obstetrics^  Johns  Hopkins  University. 


of  modern  gynecology  untrammelled  by  anti- 
quated theories  or  methods  of  treatment.  In 
xnost  instances  but  one  plan  of   treatment   is 


"  The  copy  of  '  A  Text-Book  of  Diseases  of 
Women,'  by  Penrose,  received  to-day.  1  have 
looked  over  it  and  admire  it  very  much.  I  have 
nr)  doubt  it  will  have  a  large  sale,  as  it  justly 
merits." — E.  E.  Montgomhrv.  Professor  of  Cli-n- 
irnl  Gynecology,  Jefferson  Medical  College,  P/nla. 


recommended,  to  avoid  confusing  the  student  or 
the  physician  who  consults  the  book  for  prac- 
tical guidance.    ^    J^    ^    ^    ^    Jt     ^     jt 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


A  Text-Boofc  of  MATEEUA  MEDICA, 
THERAPEUTICS,  AND  PHARMA- 

COLOGY. 
By  George  F. 
Butler,  Ph.G., 
M.D.,  Profes- 
sor of  Materia 
Medica  and  of 


BUTLER'S 
MATERIA  MEDICA 
THERAPEUTICS 
AND 
PHARMACOLOGY 


Clinical  Medicine  in  the  College  of 
Physicians  and  Surgeons,  Chicago j 
Handsome  octavo  volume  of  874 
pages.  Illustrated.  Cloth,  $4.00  net ; 
Sheep  or  Half  Morocco,  $5.00  net.    ^ 

THIRD   EDITION,  REVISED. 

A  clear,  concise,  and  practical  text-book,  adapted 
for  permanent  reference  no  less  than  for  the  re- 
quirements of  the  class-room.  The  arrange- 
ment (embodying  the  synthetic  classification  of 


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ered as  one  of  the  most  satisfactory  single-volume 
works  on  materia  medica  on  the  market."— yo?<>-- 
nal  of  the  American  Medical  Association. 


drugs  based  upon  therapeutic  affinities)  is  be- 
lieved to  be  at  once  the  most  philosoptiical  and 
rational,  as  "well  as  that  best  calculated  to  engage 
the  interest  of  those  to  -whom  academic  study 
of  the  subject  is  wont  to  offer  no  little  perplexity. 

For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

"W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


FRACTURE   OF  THE  BONES  OF  THE  FACE. 


117 


themselves  somewhat   incapacitate    the    patient    for  self- 
support,  especially  in  the  ease  of  a  woman. 

Fracture  of  the  Bones  of  the  Face. 

Fracture  of  the  nasal  hones  may  he  caused  hv  striking 
the  nose  in  falling  or  hy  hlows  from  falling  ohjects.     The 


Fig.  4. 


injury  results  not  only  in  external  deformity,  but  fre- 
quently also  in  a  narrowing  of  the  nasal  orifice.  The 
patient  complains  of  difficulty  in  breathing  and  is  often 
obliged    to    breathe    through    his    mouth.       A    thorough 


118  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  6. 

A  Case  of  Paralysis  of  the  Sympathetic  Nerve  on  the  Left 
Side,  with  Atrophy  of  the  Corresponding  Side  of  the  Face.— 

Ou  the  affected  side  of  the  lace  is  seen  a  distiuct  differeuce  in  coloring 
from  tliat  of  the  opposite  side,  which  shows  a  healthy  red  ;  the  left 
side  is  evidently  atrophied,  the  eyelid  droops  slightly,  and  the  whole 
side  of  the  face  is  covered  with  a  profuse  sweat.  The  patient,  who  is  a 
mason,  tiftj^-one  years  of  age,  when  passing  a  building  was  struck  on 
the  head  and  back  by  a  man  falling  from  the  I'ourth  story.  This  hap- 
pened on  December  :2(),  1892.  For  three  weeks  he  was  treated  in  the 
hospital  ;  after  that  at  home  I  examined  tin-  patient  ou  March  16, 
1893.  He  was  a  man  of  middle  height  and  strong  build.  In  addition 
to  the  facial  anomalies  previously  noted,  there  was  a  spastic  paralysis 
of  both  lower  extremities,  more  marked  on  the  right  side  ;  the  i)atellar 
reflexes  were  exaggerated  on  both  sides  ;  on  the  right  side  examination 
induced  clonic  spasms.  The  patient  was  unalde  to  move  his  right 
hip-joint  l)ecause  of  the  pain  caused  thereby,  and  he  walked  witli  diffi- 
culty, with  the  aid  of  two  canes.  He  was  mentally  intact.  Incapac- 
ity for  self-support,  100^. 

examination  should,  however,  always  be  made  in  these 
cases,  since  other  factors,  such  as  polypi,  syphilitic  ulcers, 
etc.,  may  in  reality  cause  the  difficulty.  Fracture  of  the 
nasal  bones  interferes  with  work  only  for  the  first  few 
weeks  after  the  accident,  and  in  some  cases  work  is  not 
interrupted  at  all.  Permanent  incapacity  for  self-support 
is  seldom  rewarded  unless  a  striking  degree  of  deformity 
follows  the  injury  or  unless  it  is  complicated  by  sinniltane- 
ous  injury  of  important  neighboring  })arts. 

Figure  4  illustrates  the  case  of  a  boy  of  fifteen  who  was  injured  by 
a  falling  weight  that  caused  a  compound  fractuie  of  the  nasal  bones. 
Very  little  deformity  is  apparent ;  the  chief  difficulty  concerned  his 
l)reathing.  The  appearance  of  the  right  nostril  is  shown  by  figure  2, 
plate  5. 

Fracture  of  the  zygoma  rarely  occurs  exce]it  in  connec- 
tion with  fracture  of  the  superior  maxilla  and  other  bones 
of  the  head.  Among  my  cases  there  were  five  of  fracture 
of  the  zygoma  alone  (without  fracture  of  the  sknll).  Some 
were  caused  bv  direct  blows  from  falling  objects,  others 
by  falls  from  a  height.  If  the  fracture  is  a  connuinuted 
one,  it  is  regularly  complicated   by  lesion  of  the   infra- 


Dd).  6: 


Lull.  Ansl.  F.  Reich tialcl.  Miinrlifu 


FRACTURE  OF  THE  INFERIOR  MAXILLA.  119 

orbital  nerve  or  of  a  branch  of  the  facial  nerve.  When 
the  former  is  involved,  the  patient  is  likely  to  become  a 
snilerer  from  tic  doulourenx,  as  a  result  of  which  he  may 
at  times  be  completely  incapacitated  for  work.  In  some 
cases  spasms  of  the  facial  muscles  may  be  observed  years 
after  the  accident ;  these  are  likely  to  cause  more  or  less 
pain,  but  may  be  quite  painless. 

In  respect  to  treatment,  some  benefit  can  usually  be 
derived  from  warm,  moist  compresses,  Priessnitz  band- 
ages, careful  massage  along  the  course  of  the  painful  nerves, 
and  weak  galvanism.  If  the  pain  is  intense,  morphin, 
antipyrin,  and  similar  remedies  should  be  administered. 

The  degree  of  incapacity  for  self-support  is  usually  pro- 
portionate to  the  pain  ;  in  severe  cases  the  patient  may  be 
totally  unfitted  for  work. 

Fracture  of  the  Superior  Maxilla. 

This  lesion  occurs  alone  only  in  rare  instances,  but  it  is 
often  observed  in  connection  with  fractures  of  the  nasal 
bones  and  zygomatic  arches,  as  well  as  with  fi'actures  of 
the  skull  in  general. 

In  carpenters  and  drivers,  among  others,  we  frequently 
meet  with  compound  fractures  involving  both  the  malar 
bone  and  the  superior  maxilla.  In  the  one  case  the  injury 
is  due  to  blows  from  falling  oljjects,  and  in  the  other  to 
kicks  from  horses,  etc.  Subjective  symptoms  are  tooth- 
ache, headache,  pain  on  mastication,  and  distress  from 
loose  teeth.  Objectively,  we  often  find  loose  teeth  and 
changes  in  the  shape  of  the  broken  jaw,  but  more  partic- 
ularly in  the  alveolar  process.  The  lesion  itself  does  not 
unfit  the  patient  for  work,  but  the  pain  to  which  it  gives 
rise  may  do  so. 

Fracture  of  the  Inferior  Maxilla. 

The  under  jaw  is  frequently  fractured  either  alone,  by 
falls  or  kicks,  or  as  an  accompaniment  of  fractures  of  the 
skull  caused  by  falls  from  a  height,  cavings-in,  etc.      In 


120  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  7. 

Contracture  of  the  Left  Trapezius  in  Consequence  of  Severe 
Contusions  of  the  Left  Side  of  the  Head  and  Body. — Se(iuel, 
hysteria.  Complete  iucapacity  Ibv  seH-support,  partly  due  to  conipli- 
catious. 

A  paiuter,  thirty-eight  years  of  age,  fell  l)ackwar<l  from  a  scaf- 
folding about  fifty  feet  high  ou  April  'AO,  1889.  Lesions:  severe  con- 
tusions of  the  left  side  of  tlie  body,  complicated  by  fracture  of  the 
ribs  and  injury  of  the  lung ;  contusion  of  the  left  scapula  and  of  the 
left  side  of  the  head,  c<miplicated  by  concussion  of  the  l)rain. 

He  remained  in  hospital  over  three  months.  The  illustration  shows 
a  peculiar  position  of  the  left  shoulder,  the  head,  and  the  left  arm  ; 
also  some  swollen  veins  on  tlie  left  side  of  the  chest  and  left  arm.  He 
received  100  %  insurance  allowance,  based  on  his  pleuritic  distnrl)- 
ances  as  well  as  the  muscular  contracture.  He  has  been  suspected  of 
simulation,  as  he  is  said  to  assume  a  more  normal  position  at  times. 

such  instances  the  fracture  is  due  to  direct  violence ;  it 
may,  however,  occur  as  the  result  of  indirect  violence,  as 
in  cases  of  violent  compression  of  the  head,  or  when,  as 
occasionally  happens,  the  coronoid  j^rocess  is  torn  off  by 
violent  contraction  of  the  temporal  nuiscle.  There  were 
ten  cases  of  fracture  of  the  inferior  maxilla  among  the 
cases  in  ray  list,  all  of  them  isolated  lesions,  caused  by 
fills  from  a  height,  and  all,  so  far  :is  could  be  ascertained, 
due  to  direct  violence.  The  injury  is  liable  to  be  followed 
by  vertical  or  lateral  displacement  of  the  fractured  jiarts 
of  the  bone.  The  displacement  may  be  apjiarent  exter- 
nally, but  can  best  be  determined  by  examining  the  line 
of  the  teeth.  In  mastication  or  on  opening  the  mouth 
the  deformity  is  often  unpleasantly  noticeal)le. 

Pi<eiido-(irfhros('s  in  this  situation  interfere  very  decid- 
edly with  the  action  of  the  jiiw,  especially  in  mastication. 
All  motion  of  the  jaw  is  painful,  and  the  nuiscles  ol"  the 
aflt'ected  side  become  markedly  atrophic. 

Dislocation  of  the  Inferior  Maxilla. 

This  lesion  is  very  rarely  seen  in  accident-practice. 

In  one  case  that  came  under  my  observation  the  patient,  a  carpen- 
ter, thirty-seven  years  of  age,  had  fallen  backward  from  a  scaffolding. 
The  under  jaw,  which  was  dislocated,  was  set  immediately  alter  the 
accident,  and  a  perfect  recovery  resulted. 


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THE    VEBTEBBAL   COLUMN.  121 


Injuries  and  Traumatic  Diseases  of  the  Neck. 

Injuries  of  the  anterior  portion  of  the  neek  are  very 
seldom  seen  alone ;  they  usually  occur  in  connection  with 
injuries  of  the  head  and  face  or  together  with  a  fracture 
or  dislocation  of  the  clavicle.  Direct  injuries  of  the  neck 
may  be  caused  by  explosions,  most  frequently  in  the 
course  of  mining  or  building  operations  to  which  blasting 
is  incidental.  Burns  of  the  neck  are  frequently  caused 
by  the  explosion  of  alcohol  or  kerosene  lamps,  and  may 
lead  to  contractures  causing  wry-neck.  Severe  injuries 
of  the  neck  involve  great  danger  to  the  important  struc- 
tures and  organs  that  it  contains,  often  entailing  grave 
consequences — a  fact  easily  understood  if  we  remember 
the  anatomy  of  the  part. 

The  muscles  most  subject  to  morbid  changes  after  trau- 
matism of  the  neck  are  the  sternocleidomastoid  and  the 
trapezius.  Contractures  of  these  muscles  produce  wry- 
neck (caput  obstipum). 


II.  THE   BODY. 

THE   VERTEBRAL   COLUMN. 

Anatomicophf/siolof/ic  Com^iderotions. — The  vertebral  colnnin  lias  tlie 
function,  among  others,  of  supporting  the  weight  of  the  body  and 
preserving  its  balance,  and,  in  accordance  with  this  function,  it 
presents  certain  normal  curves.  If  we  look  at  a  living  human  being 
from  behind,  we  note  that  the  upper  dorsal  region  of  the  spine 
appears  convex,  while  the  cervical,  lower  dorsal,  and  lumbar  regions 
appear  concave.  Dejiartnres  from  these  normal  curves  occur  among 
industrial  workers  as  the  result  of  special  vvoik  to  the  requirements 
of  which  the  spine  has  adapted  itself.  This  is  especially  the  case  if 
the  work  in  (|uestion  entails  a  one-sided  activity.  The  vertebral 
column  of  a  stone-carrier  serves  as  an  instance  of  such  changes  ;  the 
cervical  region  is  likely  to  be  markedly  convex  posteriorly,  the  U]iper 
dorsal  regi(m  is  ky])hoscoliotic,  while  in  the  lower  dorsal  and  lumbar 
regions  lordosis  is  api)art'nt.  The  position  of  tlic  .scajiuhc  and  arms, 
of  the  pelvis  and  lower  extremities,  is,  moreover,  sccondarih'  affected, 
with  the  apparent  etfect  of  shortening  some  parts  and  of  lengthening 
others.     A  certain  degree  of  deformity  of  the  thorax  is  a  necessary 


122  DISEASES  CAUSED  BY  ACCIDENTS. 

sequel  of  the  otlier  anomalies  euniuerated.  These  anomalies  are  well 
known  \mder  the  name  of  "burden-deformities."  They  increase 
gradually  and  in  exact  proportion  to  the  ett'ect  on  the  Ijody  of  the 
weight  it  has  to  support. 

The  ability  of  tlie  spine  to  support  external  burdens,  as  well  as 
the  weight  of  the  body,  while  preserving  the. balance  of  the  latter, 
is  a  proof  of  its  elasticity.  The  ehisticity  depends  cliiefly  on  the 
presence  of  the  spongy  substance  in  the  bodies  of  the  vertelyrse  and 
upon  the  intervertebral  cartihtges,  the  other  ligaments  connecting  the 
vertelu'se  acting  as  contributory  factors.  By  reason  of  this  attribute, 
the  spine  is  able  to  adapt  itself  to  compression  as  well  as  to  stretching. 
It  is  compressed,  and  thereby  shortened,  by  carrying  heavy  weights, 
and  is  lengthened  by  suspension  of  tiie  body,  while  compression  and 
stretching  both  occur  constantly  as  the  result  of  ordinary  movements 
of  flexion  and  extension  of  the  body. 

The  following  movements  are  normal  to  the  vertebral  column  :  (1) 
Anteflexion  and  retroflexion  ;  (2)  lateral  flexion  and  oblique  flexion  ; 
(3)  rotation. 

Extreme  degrees  of  mobility  are  demonstrated  by  contortionists 
(india-rnbl^er  men).  Leaving  such  unusual  degrees  of  elasticity  out 
of  consideration,  we  find  the  flexibility  of  the  spine  to  be  iu  part  deter- 
mined l)y  the  dimensions  of  the  intervertebral  cartilages  and  the  thick- 
ness of  the  bodies  of  the  vertebrae.  Thin  and  narrow  bodies  with 
thick  and  narrow  cartilages  favor  nioI)ility.  This  fact  is  illustrated  in 
the  cervical  region,  which  enjoj's  a  greater  range  of  motion  than  any 
other  region  of  the  spine,  although  this  is  partly  to  be  ascribed  to  its 
position  in  the  body,  in  which  it  is  peculiarly  free  from  constraint. 
The  hnnbar  region  holds  the  second  place,  while  the  dorsal  region  is 
relatively  inflexil)]e — partly  because  of  its  costal  articulations,  partly 
because  of  the  overlying  spinous  processes  and  tlie  tliickucss  of  the 
bodies  of  the  vertebraj.  A  consideration  of  the  influence  on  mobility 
exerted  by  the  separate  articulations  and  ligaments  would  lead  us  too 
far. 

In  discussing  the  movements  of  the  cervical  region  we  must  refer  to 
those  of  the  head,  giving  special  attention  to  the  two  upper  vertebrae 
and  their  anatomy.  The  head  is  not  placed  in  a  line  perjiendicular  to 
the  trunk,  but  at  an  angle  f)f  aV)Out  165  degrees.  Neither  is  the  neck 
perpendicular  to  either  body  or  head.  The  head  is  held  in  position  ])y 
the  antagonistic  action  of  the  muscles  attaching  it  to  the  spine  and  by 
their  muscular  tone.  Its  greatest  degree  of  flexibility  (about  80  de- 
grees), obtained  with  the  aid  of  flexion  in  the  Cervical  vertebra?,  does 
not  bring  it  to  a  right  angle  with  the  body,  but  only  to  an  angle  of 
about  85  degrees  (165  degrees  to  80  degrees). 

The  head  is  ordinarily  flexed  ])y  its  own  weight,  aided  by  the 
rectus  capitis  major  and  minor  and  the  lougus  colli  muscles,  the 
muscles  of  the  back  of  the  neck  lieing  relaxed.  Forced  flexion  is 
produced  hy  the  action  of  the  platysma,  the  scaleni  antici,  and 
probably  the  intertransversales.  Ordinary  nodding  movements  take 
place  at  the  occipito-atloid  articulation  ;  in  deep  flexion  the  whole 
cervical  region  is  called  into  play. 


THE  VERTEBRAL  COLUMN.  123 

Wheu  slightly  rotated  posteriorly  and  laterally  flexed,  the  head 
can  be  brought  to  an  angle  of  Croni  150  to  155  degrees  with  the  vertical 
axis  of  the  trunk.  In  this  movement  the  rectus  capitis  lateralis,  the 
intertrausversales,  and  the  scaleni  of  one  side  are  concerned.  On  tlie 
flexed  side  the  transverse  processes  are  approximated  ;  on  the  opposite 
side  they  are  separated.  The  oblique  processes  meanwhile  execute  a 
peculiar  movement  corresponding  to  the  shape  of  their  articular  sur- 
faces, wliich  will  be  referred  to  agaiu  later.  Ordinary  movements  of 
retroflexion  take  place,  as  a  rule,  in  the  occipito-atloid  articulation, 
and  are  produced  by  the  short  muscles  of  the  ue(;k,  the  rectus  capitis 
anticns  major  and  minor,  and  the  superior  and  inferior  obliciue. 
Marked  degrees  of  retroflexion  are  due  to  the  additional  action  of  the 
sternocleidomastoid,  tiie  spleuius  capitis,  the  trachelomastoid,  the 
complexus  and  the  l)iventer  cervicis,  the  multilidus  spina?,  and  the 
interspinales.  These  muscles  are  also  called  into  play  wheu  the 
whole  cervical  region  takes  part  in  the  movement  of  retroflexion,  and 
in  this  case  the  superior  flljers  of  the  lougissimus  dorsi  and  the  ileo- 
costalis  are  also  involved.  The  movement  in  question  can  only  be 
carried  out  when  the  muscles  of  both  sides  act  in  unison,  unilateral 
action  always  resulting  in  rotation. 

Rotation  of  the  head  in  a  vertical  axis  takes  place  in  the  atlo-odon- 
toid  articulation.  In  order  to  estimate  the  angle  of  rotation  we  must 
imagine  two  axes,  a  sagittal  and  a  transverse,  placed  at  a  right  angle 
to  each  other.  This  gives  us  an  angle  of  rotation  of  about  75  degrees. 
This  demands  the  acticm  of  the  whole  cervical  region  of  the  spine,  and, 
of  course,  lowers  the  level  of  the  axis  of  rotation.  Ordiuary  rotation 
at  the  occipito-atloid  articulation  is  produced  by  the  action  of  the  in- 
ferior oblique  of  one  side — the  right  inferior  obliipie,  for  instance,  turn- 
ing the  head  to  the  right.  Farther  degrees  of  rotation  are  due  to  the 
action  of  the  sternocleidomastoid  of  the  opposite  side,  causing  at  the 
sime  time  a  slight  inclination  of  the  face  toward  the  side  of  the  acting 
muscle.  Rotation  may  call  into  play  all  tlie  muscles  of  one  side, 
which,  wlien  acting  in  unison  with  the  muscles  of  the  opposite  side, 
produce  anteflexion  or  retroflexion  of  the  neck. 

According  to  H.  Meyer,  the  spine,  in  executing  the  movement  of 
flexion, — taking  the  distance  between  the  promontory  of  the  sacrum 
to  the  anterior  tubercle  of  the  atlas  as  the  radius, — describes  an  arc  of 
71  degrees  in  an  anteroposterior  plane.  The  cervical  region  takes  the 
chief  part  in  this  movement.  If  the  radius  is  expressed  h\  the  dis- 
tance between  the  promontory  and  the  seventh  cervical  vertel>ra,  the 
angle  of  flexion  eijuals  only  M  degrees,  of  which  .31  degrees  are  due 
to  the  action  of  the  three  lower  hnnbar  verteV)ne.  The  general  rule 
ajiplies  to  the  spine  that  the  intervertebral  discs  are  compressed  during 
flexion  on  the  concave  side  of  the  spine,  while  tliey  are  freed  from 
pressure  or  stretched  on  its  convex  side.  On  anteflexion  the  ligaments 
connecting  the  spinous  processes — the  interspinous  and  supraspinous 
ligaments,  as  well  as  the  ligamentum  flava — are  subject  to  traction. 
The  spinous  processes  are  appreciably  separated  during  this  move- 
ment. At  the  same  time  the  intervertebral  discs  undergo  compres- 
sion anteriorly,  while  posteriorly  they  are  stretched.     On  flexion,  the 


124  DISEASES  CAUSED   BY  ACCIDENTS. 

spine  w;is  increased  exactly  11  o  cm.  in  length  in  a  man  twenty-fonr 
years  ol"  age,  the  measurements  iucluding  the  distance  from  the  atlas 
to  the  end  of  the  sacrum.  The  muscles  of  the  back  are,  of  course, 
included  in  the  stretching  of  the  posterior  part  of  the  spine.  During 
the  process  of  anteflexion  the  articular  processes  of  each  vertebra  glide 
upward  on  the  corresponding  processes  of  the  vertebra  next  below  it, 
the  whole  spine  being  at  the  same  time  slightly  rotated  on  its  trans- 
verse axis. 

In  executing  the  movement  of  forced  anteflexion  tlie  thiglis  are 
fixed  and  both  hips  take  part  in  the  process.  In  young  persons  the 
angle  thus  formed  between  trunk  and  thighs  equals  about  75  degrees. 
On  anteflexion,  to  which  the  weight  of  the  body  contributes,  the 
abdominal  muscles  contract,  especially  the  rectus  and  iliopsoas  of  each 
side,  while  the  muscles  of  the  back  are  stretclied.  Even  while 
stretched  these  muscles  are  to  a  certain  extent  contracted,  as  a  precau- 
tion against  falling  over  forward.  Since  the  spinal  column  is  length- 
ened posteriorly  on  flexion,  we  may  assume  that  it  is  shortened  anteri- 
orly to  the  same  extent.  The  opposite  condition  o])tains  on  retnjflexion, 
the  intravertebral  discs  being  compressed  posteriorly,  while  anteriorly 
they  are  freed  from  pressure.  The  articular  processes  of  each  vertebra 
glide  downward  on  the  corresponding  processes  of  the  vertebra  next 
below,  while  the  spine  is  rotated  on  its  transverse  axis  in  the  direction 
opposite  to  that  which  it  took  on  anteflexion.  The  last  two  articular 
processes,  those  of  the  fifth  luml)ar  vi-rtebra,  glide  down  into  the  lum- 
bosacral fossa  of  the  first  sacral  vertc])ra. 

Retroflexion  is  chiefly  accomplished  in  the  cervical  region  ;  the 
lumbar  region  takes  the  next  chief  part,  while  the  dorsal  region  under- 
goes relatively  little  change  ;  its  share  in  the  process,  however,  should 
not  be  underrated.  In  a  man  tvv(mty-four  years  of  age  the  cervical 
region ,  measuring  from  the  tubercle  of  the  atlas  to  the  spinous  process 
of  the  seventh  cervical  vertebra,  was  shortened  posteriorly  by  7  cm., 
while  the  dor.sal  and  lumbar  region  together,  measuring  from  the 
spinous  process  of  the  seventh  cervical  vertebra  to  the  end  of  the  sa- 
crum, was  shortened  by  only  6  cm.  The  total  shortening,  therefore, 
was  1 1  cm.  Movement  in  the  hip-joint  during  retroflexion  is  normally 
very  slight,  being  greatly  limited  by  the  action  of  the  iliofemoral 
ligament.  The  long  muscles  of  the  back  contract,  while  the  abdom- 
inal muscles,  especially  tiie  rectus  and  iliopsoas,  are  stretched. 

Lateral  flexion,  if  we  leave  the  cervical  region  out  of  consideration, 
is  executed  almost  altogether  in  the  lumbar  region,  or,  rather,  in  the 
lumbar  region  and  the  two  lowest  dorsal  vertebr;c.  Pure  lateral 
flexion  without  rotation  can  be  carried  to  an  angle  of  ^r>0  degrees 
without  much  diflicully  by  a  man  of  middle  age.  Lateral  flexion  with 
rotation  is  accomiilislicd  by  the  action  of  the  semispinalis  dor.si  and 
mnltilidus  s])inic  of  one  side,  and  can  be  carried  to  an  angle  of  130 
degrees.  The  interverteliral  discs  are  thereby  compres.sed  on  the 
flexed  side.  During  this  movement  the  articular  processes  on  the 
flexed  side  glide  somewhat  downward  on  the  sides  of  the  processes  of 
the  veitebra  next  above  ;  the  articular  ])rocesses  of  the  opjiosite  side 
(that  which  is  stretched)  are  correspondingly  elevated.    The  conforma- 


THE  SPINAL  C0LU3IN  AND  RIBS.  125 

tion  of  the  boues  makes  this  movemeut  necessarily  a  limited  oue. 
The  slaut  of  the  articular  surfaces  of  the  articular  i)rocesses  precludes 
deep  Literal  flexiou  without  rotatiou.  The  nuiscles  that  take  part  in 
lateral  flexion  are  the  iutertransversales,  and,  in  the  dorsal  region,  the 
internal  intercostals  as  well. 

Rotation  of  the  spine  is  chiefly  produced  bj'  muscular  action  ;  the 
cervical  region  is  most  adapted  to  this  movemeut,  which  is  executed 
with  greater  difficulty  in  the  luml)ar  region  and  is  least  possible  in 
the  dorsal  region.  Tlie  articular  processes  move  as  follows  :  wlien 
rotation  takes  place  from  left  to  right,  the  inferior  articular  processes 
of  the  lett  side  of  each  vertebra  are  pressed  against  the  sujjerior 
articular  processes  of  the  vertebra  next  below. 

Relation  of  the  Spinal  Column  to  the  Ribs. 

The  dorsal  region  is  the  least  mobile  of  the  several  regions  of  the 
spine,  a  tact  which  is  largely  due  to  its  connection  with  the  ribs, 
especially  with  the  tirst  ten,  which,  by  their  articulation  with  the 
sternum  in  front,  form  the  l)ony  framework  of  the  thorax.  The  ril)s 
are  connected  both  with  the  bodies  of  the  vertebnv  and  with  their 
transverse  processes.  The  heads  of  the  second  to  the  ninth  ribs,  in- 
clusive (sometimes  of  the  first  to  the  tenth,  inclusive),  articulate  each 
by  a  double  facet  with  two  vertebise.  The  ridge  on  the  head  of  the  rib 
separating  the  two  facets  lies  close  to  the  intervertebral  disc,  and  is 
attached  to  the  latter  by  means  of  a  small  tibrocartilaginous  ligament, 
by  which  the  articular  cavity  inside  the  capsular  ligament  is  divided 
into  two  parts.  The  riljs  also  articulate  with  the  transverse  processes 
of  the  vertebrae,  and,  in  addition,  there  are  ligaments  passing  from  the 
necks  of  the  ribs  to  the  transveise  processes  of  the  vertebrae. 

The  ribs,  therefore,  take  part  in  all  movements  of  the  spine. 
Through  their  articulations  with  the  bodies  and  transvei-se  processes 
of  the  vertebrae  they  have  a  little  independent  action,  but  this  is  very 
limited.  On  anteflexion  of  the  spine  the  ribs  are  separated  posteriorly 
and  approximated  anteriorly  ;  on  retroflexion  this  process  is  reversed  ; 
on  lateral  flexion  they  are  approximated  on  the  side  of  flexion  and 
separated  on  the  opposite  side.  The  sympathetic  nerve  passes  down 
the  posterior  wall  of  the  thorax  beside  the  spine,  in  which  position  it 
is  exposed  to  injury  from  fractures  of  the  transverse  processes  or  of  the 
ribs  near  their  vertebral  attachments. 

The  interarticular  ligaTuent,  as  well  as  the  other  ligamentous  at- 
tachments l)etween  the  ribs  and  the  vertebnc  or  their  processes,  may 
be  lacerated  as  a  result  of  tbrced  movements  of  the  spine.  Such  in- 
juries can  hardly  be  diagnosed  during  life,  unless  there  is  a  dislocation 
of  the  ribs  at  tlie  same  ])oints  that  can  be  di-scovered  liy  aid  of  X-ray 
photographs.  It  is  well,  nevertheless,  to  remember  their  possible 
occurrence. 

The  spinous  processes  furnish  us  with  the  only  anatomic  means  of 
determining  the  level  of  an  injury  of  the  verteljrae  in  a  living  person, 
or  of  the  lesion  of  the  cord  or  spinal  nerves  that  may  be  conseiiuent 
upon  it.  It  is  important,  however,  to  be  acquainted  with  the  relation 
existing  between  the  spinous  processes,  spinal  nerves,  and  segments 


126 


DISEASES  CAUSED  BV  ACCWEXm. 


Motor. 


Sternomastoid. 
1  Trapezius, 
j  Diaphragm. 


(uluar  lowest). 


Intercostal     niiis 
cles. 


Abdominal      mu; 
cles. 


Flexors  of  hip.       , 

I 

j-  E.X  tensors  of  knee. 

Adductors,  ^ 
Abductors. 
Ex t  e  n - 


hip.  I 


sors  (?) 


Flexors  of  knee(?) 

I  Muscles    of    leg 
r     moving  toot. 

Perineal  and  anal 
muscles. 


Sensory. 

Neck  and  scalp. 
Neck  and  shoulder 

Shoulder. 

Arm. 

Hand. 


Reflex. 


Front  of  thorax. 
Ensiform  area. 


Abdomen  (nmbili 
cus,  tenth). 


Buttock    (upper 
part). 

Groi  n  and  scrotum 
(front). 

router  side. 
Thigh  .|  front. 

tinner  side 

Leg,  inner  side. 
Buttock,   lower 

part. 
Back  of  thigh 

Leg   «.>.'    ^"'=«'^' 
foot 


Scapular. 


Epigastric. 


C  r  e  m  a  s  - 
teric. 

•  Knee-jerk. 


and  ^e?'<=«P' 
'  {  inner 
'         (    part. 


Foot-clonus. 
Plantar. 


P  e  r  i  n  e  u  m    and 
anus. 

Skin  from  coccyx 
to  anus. 


Fig.  5. — ^Diagram  and  table  showing  tbe  approximate  relation  to  the  f^pinal  nerves  of 
the  various  motor,  sensory,  and  reflex  functions  of  the  spinal  cord. 


TEE  SPINAL  COLUMN  AND  BIBS. 


127 


of  the  spinal  cord  in  respect  to  level,  since  they  do  not  by  any  means 
correspond  in  this  particular.  The  accompanying  table,  according  to 
Gowers  (Fig.  5),  is  a  valuable  guide  in  determining  these  points,  as 


c 

2C 

• 

3C 

2 

4C 

iC 

3 

6C 

JC 

4 

8C 

i 

iD 

6 

2D 

sD 

7 

D 

4D 

1 

5D 

2 

6D 

3 

8D 

4 

7D 

S 

9D 

6 

lOD 

7 

iiD 

I2D 

8 

iL 

9 

2L 

3L 

10 

4L 

11 

5L 

I 

2 

3S 

4 

5 

13 

L 

I 

Co 

2 

Fig.  6. 


well  as  in  settling  questions  of  motor,  sensory,  and  reflex  functions  ; 
while  the  schema  of  Keid  (Fig.  6)  shows  the  relation  between  the 
spinous  processes  and  segments  of  the  cord. 


1 28  DISEASES   CA USED  BY  A CCIDENTS. 


I.  GENERAL  SYMPTOMS  OF  TRAUMATIC  DISEASES  OF 
THE  SPINAL  CORD. 

In  all  cases  of  injury  affecting  the  spinal  colnmn  the 
question  of  involvement  of  the  cord  is  of  vital  importance  ; 
a  short  review  of  the  traumatic  diseases  of  the  cord  seems, 
therefore,  in  place  at  tliis  juncture. 

It  may  ))e  said,  speaking  in  general  terms,  that  injuries 
of  the  cord  are  followed  l)y  (1)  sensory  disturbances  and 
(2)  motor  disturbances.  The  sensory  disturl)ances  consist 
in  anomalies  of  the  tactile,  muscle,  or  temj)erature  senses, 
and  of  the  sense  of  pain  (anesthesia,  analgesia,  hyperes- 
thesia, girdle  sensation).  Motor  disturbances  are  expressed 
by  ])aralysis  or  exaggerated  muscular  activity  (nuiscular 
rigidity,  sj)asins,  contractures,  neur(>])athi(^  contractures). 
The  various  forms  of  clonic  muscular  spasms  may  also  be 
included  among  the  motor  disturbances — muscle-waves, 
fibrillary  contractions,  tremor,  tetany,  etc. 

The  condition  of  the  reflexes  is  an  important  index  to 
the  diseases  of  the  cord.  If  they  are  normal,  we  can  con- 
clude that  the  section  of  the  cord  through  which  the  reflex 
loop  passes  is  unaflected.  AVhen,  on  the  other  hand,  the 
reflexes  are  found  to  be  exaggerated,  diminished,  or  com- 
pletely lost,  we  know  that  the  part  of  the  cord  in  question 
is  diseased. 

[The  most  inq)ortant  reflex  is  the  knee-jerk.  Innnedi- 
ately  after  a  severe  contusion  to  any  part  of  the  cord,  the 
knee-jerks  may  be  very  much  diminished  or  unobtainable. 
If  the  injury  is  above  the  lumbar  region,  the  absence  of 
the  knee-jerk  alone  is  not  suflicient  evidence  for  a  total 
transverse  lesion  ;  for  with  the  resorption  of  blood,  and 
recovery  from  shock  to  the  nerve-fibers  and  nerve-cells, 
the  knee-jerks,  though  they  were  alisent  at  first,  may  return 
or  may  become  exaggerated.  If  the  knee-jerks  have  not 
returned  by  the  end  of  a  week  or  ten  days,  however,  it  is 
certain  that  the  lesion  is  extensive  and  severe. 

In  lesions  in  the  lumbar  region  and  lower  down,  l)oth 


THE  SPINAL  CORD.  129 

in  the  cord  and  in  the  nerve-plexus,  the  i<nee-jerk  is  less 
reliable  as  an  index  of  the  extent  of  the  injury  ;  for  these 
regions  are  the  seats  of  the  knee-jerk  mechanism,  and 
even  partial  injuries  here  are  very  likely  to  destroy  it. — 
Ed.] 

The  reflexes  are  exaggerated  in  case  of  (1)  increased 
irritability  of  the  gray  substance  of  the  cord,  as  a  result 
of  inflammation  or  trophic  disturbances  ;  (2)  when  the 
reflex  centers  in  the  cord  are  cut  oif  from  the  inhibitory 
control  of  the  brain. 

When  both  these  causes  act  together  in  a  given  case, 
the  reflexes  are  exaggerated  to  an  extreme  degree.  The 
exaggeration  of  reflexes  due  to  fatigue  does  not,  of  course, 
belong  in  this  category.  The  reflexes  are  diminished  or 
lost  in  conse(pience  of  injury  or  disease  of  the  anterior 
nerve-roots  (motor-paralyses),  or  of  injury  or  disease  (»f 
the  posterior  nerve-roots  (anesthesia),  or,  furthermore,  in 
consequence  of  lesions  of  the  gray  substance  of  the  cord 
or  of  the  lateral  pyramidal  tracts.  The  reflexes  that  espe- 
cially deserve  attention  are  : 
1.   Cutaneous  reflexes  : 

(«)  Plantar  reflex  :  Contraction  of  the  muscles  of 
the  foot  on  irritation  of  the  sole.  (Lower  part  of 
the  lumbar  enlargement.) 
(6)  Gluteal  reflex  :  Contraction  of  the  gluteal  muscles 
on  irritation  of  the  skin  of  the  gluteal  region 
(fourth  and  fifth  lumbar  segments). 
(c)  Cremaster  reflex  :  Retraction  of  the  testicle  on 
irritation  of  the  skin  on  the  inner  surface  of  the 
thigh  (first  lumbar  segment), 
(f?)  Abdominal  reflex  :  Contraction  of  the  abdominal 
muscles  on  irritation  in  the  region  of  the  linea 
alba  (eleventh  dorsal  segment).  [Babinski  has 
recently  described  a  previously  unknown  pathologic 
reflex.  It  has  long  been  known  that  irritation  of 
the  sole  of  the  foot  produces  flexion  of  the  toes, 
especially  marked  in  the  great  toe.  Babinski  calls 
9 


130  DISEASES  CAUSED  BY  ACCIDENTS. 

attention  to  the  fact  that  in  h'sions  of  the  }\yranii<hil 
tract  this  reflex  is  reversed  :  /  e.,  irritation  pro- 
duces extension  (dorsal  flexion)  in  tlie  toe.  This 
symptom  is  a  fairly  constant  and  reliable  one.  It 
is  specially  useful  in  the  diagnosis  of  hysteria  from 
organic  disease. — Ed.] 

2.  Of  the  tendon-reflexes  we  take  note  of  the  patellar 
reflex,  the  triceps  reflex,  and  the  reflex  of  the  tendo 
Achillis.  Loss  of  the  patellar  reflex  indicates  disease  of 
the  posterior  gray  columns  of  the  cord  at  the  level  of  the 
second  to  fourth  lumbar  nerves. 

The  ankle-clonus  is  a  reflex  belonging  only  to  patho- 
logic conditions. 

Incoordination  is  another  symptom  indicative  of  disturb- 
ance of  motility.  It  depends  upon  a  morbid  condition 
of  the  muscle-sense,  aufl  is  shown  by  uncertain  and  pur- 
poseless movements  of  the  hands,  fingers,  and  legs. 

The  gait  is  distinguished  as  paretic,  ataxic,  and  spastic. 

Other  symptoms  of  lesions  of  the  cord  are  vasomotor 
disturbances,  evidenced  by  lowering  of  the  temperature,  a 
feeling  of  cold,  cyanosis  of  the  skin,  edema,  and  some- 
times necrotic  ulcers. 

Bed-sores  are  a  regular  accompaniment  of  recent  injuries 
of  the  cord.  As  a  result  patients  are  liable  to  die  of  gen- 
eral sepsis  in  spite  of  every  precaution. 

The  condition  of  the  muscles  is  important.  Atrophy 
becomes  more  and  more  marked ;  electric  stimulation 
elicits  the  reaction  of  degeneration. 

The  internal  organs  afl'ected  in  consequence  of  injuries 
of  the  cord  are  : 

1.  The  bladder. 

2.  The  intestines  (meteorism). 

3.  The  kidneys. 

4.  The  heart  is  less  frequently  affected ;  irregularities 
in  its  action  are,  however,  sometimes  noticed. 

Paralysis  of  the  bladder  is  a  common  symptom  in  dis- 
eases of  the  cord.     This  condition  leads  to  the  retention 


THE  SPINAL  CORD.  131 

of  urine,  necessitating  catheterization,  or  to  incontinence 
of  urine.  The  urine  frequently  contains  casts,  phosphates, 
etc.  In  the  kidney,  anemia  and  anemic  necrosis  have 
been  observed  by  Wagner  and  Stolper.  Calculi  composed 
of  phosphate  and  carbonate  of  lime  have  been  found  in 
the  bladder. 

In  all  cases  of  traumatism  involving  the  cord  it  is  essen- 
tial to  the  prognosis  to  learn  whether  the  lesion  is  partial 
or  complete.  According  to  AVagner  and  Stolper,  the 
symptoms  of  total  transverse  lesions  are  as  follows  -. 

1.  Motor  and  sensory  paralysis,  equally  marked  on 
both  sides  of  the  body. 

2.  Loss  of  all  nervous  irritability  in  the  region  affected 
by  the  paralysis. 

3.  Loss  of  the  patellar  reflexes. 
In  addition  w^e  find  : 

4.  Paralysis  of  bladder  and  rectum. 

5.  Vasomotor  paralysis. 

Symptoms  of  partial  lesions,  according  to  the  same 
authors,  are  : 

1.  Motor  and  sensory  disturbances  having  an  unequal 
distribution. 

2.  The  two  sides  of  the  body  are  especially  liable  to 
be  unequally  affected  (asymmetric  paralysis). 

3.  There  are  signs  of  both  motor  and  sensorv  irrita- 
bility. 

4.  The  patellar  reflexes  are  present  in  almost  all  cases ; 
they  are  usually  exaggerated  and  are  often  unequal  as  to 
the  two  sides.      They  are  never  permaneutly  lost. 

5.  Variations  in  degree  of  both  motor  and  sensory 
paralyses.  The  paralyses  have  a  gradual  onset  and  remain 
incomj)lete. 

6.  Partial  or  complete  restoration  of  functional  power 
takes  place  within  one  to  two  weeks. 

The  prognosis  depends  in  part  on  the  level  at  ichich  the 
cord  is  injured.  Lesions  due  to  traumatism  usually  in- 
volve its  transverse  diameter,  destroying  the  nerve-centers 


132  DISEASES  CAUSED  BY  ACCIDENTS. 

at  that  level  and  severing-  or  injuring  the  nerve-paths 
crossing  it.  It  is  a  help  in  fonning  an  opinion  of  a  case 
to  imagine  that  the  cord  is  divided  into  a  ninnber  of  trans- 
verse sections.  In  examining  accident-cases  we  find  that 
the  spinous  processes  of  the  vertebrae  are  useful  guides, 
while  the  schemata  of  Gowers  and  Reid,  together  with 
careful  observation  of  the  symptoms,  aid  us  further  in 
coming  to  a  correct  conclusion  as  to  the  level  of  the 
lesion. 

2.    INJURIES    OF   THE  SPINAL    CORD;    CONCUSSION    OF 
THE  CORD. 

The  actual  lesion  caused  by  this  injury  is  unknown,  the 
opinions  usually  accepted  being  only  hypothetic.  Emi- 
nent authors,  like  Kocher,  and  Wagner  and  Stolper, 
deny  the  occurrence,  or  even  the  possibility  of  the  occur- 
rence, of  a  concussion  of  the  cord.  It  can  not  be  disputed 
that  all  the  symptoms  that  are  attributed  to  concussion 
may  just  as  well  be  due  to  hemorrhage  into  the  substance 
of  the  cord  or  its  meninges.  The  symptoms  of  shock,  too, 
are  in  no  wise  different  from  those  of  concussion  of  the 
brain.  The  authors  who  affirm  the  existence  of  this 
lesion  declare,  in  the  absence  of  demonstrable*  anatomic 
changes,  that  it  is  a  molecular  affection.  Oppenheim  is 
positive  that  hemorrhages  into  the  cord  and  meninges  may 
take  place  without  external  injury  to  or  laceration  of  these 
structures.  He  even  states  that  lacerations  of  the  sub- 
stance of  the  cord  may  occur  in  consequence  of  concus- 
sion of  the  latter  or  of  the  body  as  a  whole.  In  direct 
opposition  to  these  teachings  we  have  the  opinion  of  Wag- 
ner and  Stolper,  based  on  the  observation  of  a  large 
number  of  cases.  These  authors,  as  previously  stated, 
deny  the  occurrence  of  the  injury  in  question.  If  the 
cord  is  lacerated,  it  is  certainly  incorrect  to  speak  of 
"molecular  changes,"  since,  in  this  case,  there  is  a  definite 
anatomic  lesion. 

Traumatic  compression  of  the  cord  is  stated  by  Wagner 


INJURIES  OF  THE  SPINAL  3IENINGES.  133 

and  Stolper  to  be  an  injury  giving  definite  clinical  symp- 
toms, but  not  causing;  demonstrable  anatomic  chang^es. 
The  symptoms  to  which  it  gives  rise  are  ascribed  to  dis- 
turbances of  circulation  involving  the  lymphatics  as  well 
as  the  blood-vessels,  and  leading  to  a  temporary  paralysis 
of  the  nerves.  As  soon  as  the  nervous  elements  are  re- 
lieved from  compression  their  functional  power  returns  ; 
if  the  pressure  increases,  however,  the  same  lesions  of  the 
cord  are  produced  as  in  cases  of  acute  contusion. 

Contusion  of  the  cord  is  an  injury  that  is  usually  ob- 
served in  connection  with  a  fracture  or  dislocation  in  the 
vertebral  column,  the  cord  being  bruised  by  the  arches. 
The  localized  symptoms  that  follow  the  injury  will  be  re- 
ferred to  later  on.  Contusions  may  also  be  caused  by  the 
sudden  bend  in  the  spine  in  cases  of  sprains.  Another 
consequence  of  sprains  is  sometimes  seen  in  the  stretching 
of  the  cord  in  its  long  axis.  As  the  result  of  the  strain 
to  which  it  is  subjected,  the  cord-substance  gives  w^ay  at 
the  point  of  least  resistance  ;  it  is  more  or  less  torn  and  is 
infiltrated  with  extra vasated  blood. 

The  symptoms  of  contusion  depend  upon  the  extent  of 
the  lesion,  which  may  partly  or  completely  sever  the  cord 
in  its  transverse  diameter.  In  some  cases  we  find  the 
symptoms  characteristic  of  the  unilateral  lesion  of  Brown- 
Sequard. 

3.  INJURIES  OF  THE  SPINAL  MENINGES. 

Lesions  of  the  dura  mater  do  not  give  rise  to  special 
functional  disturbances,  unless  complicated  by  involve- 
ment of  the  nerves. 

Wounds  and  lacerations  of  the  dura  mater  do  not  cause 
noteworthy  functional  disturbances,  unless  nerves  are  in- 
volved in  the  injury.  The  cicatri(^es  that  follow  may, 
however,  exert  pressure  or  traction  on  the  nerve-roots 
passing  out  at  the  level  of  the  lesion,  producing  conditions 
of  chronic  inflammation  with  sym])toms  of  irritation  and 
more  or  less  marked  functional  disturbances. 


134  DISEASES  CAUSED  BY  ACCIDENTS. 

Extramedullary  hemorrhages  (heniatorrhaehi.s)  [Trau- 
matic extranieduUary  hemorrhage,  occurring  as  a  distinct 
lesion  without  injury  to  the  spinal  cord,  is  extremely  rare, 
if  it  ever  occurs. — Ed.]  may  take  place  internal  or  ex- 
ternal to  the  dura  mater.  If  the  dura  remains  intact,  the 
blood  passes  into  the  epidural  space,  between  the  dura  and 
the  bone ;  otherwise  it  enters  between  the  dura  and  arach- 
noid, forming  a  subdural  hematoma.  The  hemorrhage  is 
chiefly  venous,  and  shows  a  tendency  to  flow  downward, 
so  that,  although  the  hemorrhage  may  have  its  origin  in 
the  cervical  region,  it  may  spread  through  the  entire 
spinal  canal.  After  fracture  of  the  base  of  the  skull, 
too,  blood  extravasations  have  been  observed  in  the  spinal 
canal.  Extramedullary  hemorrhages  are  not  of  frequent 
occurrence  as  a  separate  lesion,  and,  according  to  the 
results  obtained  from  experiments  on  dogs,  they  cause  no 
permanent  injury  to  the  cord  itself.  In  these  experiments 
the  paralyses  disappeared  after  two  days.  The  chief 
symptoms  are  as  follows  :  pain  running  down  the  spine, 
lancinating  pains  in  the  extremities,  fibrillary  muscular 
spasms  along  the  ribs,  muscle-waves,  tremor,  clonic  and 
toni(;  muscular  spasms.  Paralyses  are  seldom  seen ; 
bladder  and  rectum  are  not  aflPected. 

The  spinal  meninges  may  be  secondarily  infected  in 
consequence  of  Avounds  or  of  metastatic  processes, — 
tuberculosis,  for  instance, — and  may  become  the  seat  of 
an  inflammation  that  subsequently  assumes  a  purulent 
character  (acute  meningomyelitis ;  pachymeningitis  and 
leptomeningitis).  If  the  suppurative  process  is  intense, 
it  is  probably  always  fatal.  In  less  severe  cases  it  may 
lead  to  the  formation  of  extensive  adhesions  between  the 
dura  mater  and  the  j)ia  mater,  wliich  again  cause  disturb- 
ances of  circulation  in  both  the  lynq^hatic  vessels  and 
blood-vessels  of  the  cord,  and,  consequently,  compression 
of  the  latter. 


TEE  SPINAL  CORD.  135 


4.  TRAUMATIC   HEMORRHAGES  IN  THE  SPINAL  CORD. 

[Traumatic  heinatomyelia  is  one  of  the  most  interesting 
of  traumatic  disorders  of  the  nervous  system.  In  severe 
general  injuries,  when  it  occurs  as  a  complicating  factor, 
its  individuality  is  usually  lost  in  the  general  mutilation. 
But  when  it  constitutes  the  chief  lesion,  it  very  often  has 
distinctive  and  recognizable  symptoms.  In  its  most  char- 
acteristic form  it  occurs  without  any  bone-injury  being 
demonstrable  during  life,  and  many  autopsies  have  proved 
that  such  a  lesion  in  the  spinal  cord  is  possible  without 
the  integrity  of  the  spinal  column  being  interfered  with. 
This  variety,  which  I  have  called  "primary "  hemato- 
myelia  (the  word  primary  indicating  that  the  bleeding 
results  directly  from  the  violence,  without  the  inter- 
vention of  crushing  or  [)ressure  by  bone),  is  found  almost 
exclusively  in  the  lower  cervical  and  upper  thoracic 
regions,  and  results  from  sudden  forced  flexicjn  or  exten- 
sion of  the  neck  :  e.  g.,  diving  in  shallow  water.  The 
symptoms  come  on  immediately. 

Since  hemorrhage  occurs  first  and  most  freely  in  the 
gray  matter,  the  symptoms  of  primary  hematomyelia  are 
gray-matter  symptoms  :  viz.,  atrophic  paralysis  with 
rapidly  ensuing  atrophy  and  diminution  of  electric  excita- 
bility. Since  the  gray  matter  has  to  do  with  the  trans- 
mission of  sensations  of  temperature  and  pain,  certain  of 
these  c-ases  present  very  interesting  sensory  symptoms. 
They  are  a  loss  of  the  ability  to  recognize  heat  or  cold  or 
to  feel  pain,  although  touches  continue  to  be  normally  per- 
ceived. Thus  the  sensory  sym[)toms  are  those  of  syringo- 
myelia. In  some  cases  sensory  symptoms  are  altogether 
absent. 

In  addition  to  the  gray-matter  symptoms  of  primary 
hematomyelia,  there  are  present  others  indicating  pressure 
on  the  pyramidal  tracts.  These  consist  in  paralysis  or 
weakness  in  the  legs,  loss  of  bladder  control,  etc.  The 
knee-jerks  may  be  abolished  at  first,  to  return  in  a  few 


136  DISEASES  CAUSED  BY  ACCIDENTS. 

days  and  to  become  exaggerated.  Often  tliey  are  exag- 
gerated or  hyperactive  from  the  outset.  Sometimes  they 
remain  unaffected  throughout. 

These  symptoms  vary,  in  extent  and  association,  with 
the  amount  of  hemorrhage.  In  slight  cases  many  of  the 
cardinal  symptoms  of  spinal-cord  injury  are  absent.  In  a 
very  extensive  hemorrliage  the  clinical  individuality  may 
be  masked  and  the  case  may  appear  to  be  one  of  ordinary 
transverse  lesion.  The  ones  presenting  the  syringomyelic 
type  of  anesthesia  are  the  most  characteristic.  When  the 
hemorrhage  is  very  slight,  the  paralysis  may  affect  the 
muscles  of  one  member  only,  without  any  sensory  symp- 
toms. 

The  condition  known  as  diplegia  brachialis  traumatica, 
or  paralysis  of  both  arms  following  injury  to  the  neck,  is 
due,  in  my  opinion,  to  hemorrhage  into  the  cord-substance, 
and  not  to  extramedullary  hemorrhage,  as  is  generally 
taught. 

These  cases  of  primary  hematomyelia  should  be  recog- 
nized more  readily  than  they  seem  to  be,  for  they  })resent, 
in  general,  the  most  hopeful  outlook  of  any  spinal-cord 
injury.  The  symptoms  are  alarming  at  first,  but  they 
often  recede  very  rapidly,  and  after  being  totally  paral- 
yzed, many  of  these  patients  are  able,  in  a  few  months, 
to  resume  their  occupations. 

Case  of  primary  hcniatomyclia  presenting  the  si/rin(jomi/eIic  type  of 
anesthesia.  On  or  about  Jiiue  20,  1898,  a  strong  man  I'ell  tliirty  feet 
through  a  hatchway  and  was  instantly  paralyzed  in  ])oth  legs.  He 
was  taken  to  the  Hudson  Street  Hospital,  in  the  service  of  Dr.  P.  R. 
Bolton.  Symptoms  :  Arms  uualfeoted  in  any  way  ;  complete  motor 
paraplegia  of  legs,  with  retention  of  urine  ;  diminution  (almost  ex- 
tinction) of  botli  kiu^e-jerks.  Sensil)i]ity  to  touch  and  pain  were  nor- 
nuii,  Imt  a  pronounced  thermo-anesthesia  was  present  below  the  ui]i- 
ples.  No  bed-sores.  Recovery  was  very  rapid.  The  retention  of 
urine  disappeared  in  ten  days,  aiul  in  six  weeks  the  patient  could 
walk  unsupported.  On  August  23,  1898,  the  following  notes  were 
made  :  The  man  walks  easily  and  without  a  marked  limp,  although 
the  right  leg  is  stiff.  All  movements  of  the  lower  extremities  are 
performed  ((uickly  and  with  good  force.  Both  kuee-jeiks  have 
become  exaggerated,  and  there  is  also  double  ankle-clonus.  Thermo- 
anesthesia has  iu  large  part  disappeared,  though  traces  of  it  are  still 


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THE  SPINAL  CORD.  137 

preseut  in  the  legs,  especially  the  left.  At  the  first  examination 
the  verte))ial  column  appeared  normal  ;  at  this  second  examination 
there  was  a  kyphosis  in  the  upper  dorsal  region.  The  patient  liad 
secured  a  i)lace  as  night-watchman,  and  said  he  could  iieribrm  his 
duties  witliout  fatigue.  Thus  in  two  months  from  the  receipt  of 
the  injury  this  man  had  recovered  from  a  complete  motor  para- 
plegia, witli  ])lacl(ler- paralysis,  and  had  again  hecome  a  bread  winner. 

Cose  of  j)iim<try  Itcmatinnydia  (jiciny  ike  Hymptom-complex  knoicn  as 
diplegia  hravliialis  traumatica. 

A  man  aged  fifty-four  years  on  December  2,  1899.  was  run  into  by 
a  light  carriage,  jfe  became  unconscious  momentarily,  and  is  unable 
to  state  exactly  how  the  accident  occurred.  Thinks  that  he  was  struck 
in  the  neck  ))y  a  sliaft  and  that  then  the  carriage  passed  over  liim. 

Examination  .shortly  after  the  accident  showed  fracture  of  two  ribs, 
scalp-wounds,  and  paralysis  of  both  upper  extrendties.  The  legs  were 
unaffected.  There  was  no  disturbance  with  either  bladder  or  rectum, 
and  the  patient  was  unaware  of  any  disturliance  in  sensation.  He  was 
treated  for  ten  days  in  the  hospital  and  then  came  to  the  Vanderljilt 
clinic,  where  I  examined  him.  During  his.stay  in  the  hospital  he  suffered 
severe  pain  in  the  neck,  which  radiated  down  both  arms. 

The  foUowing  are  my  notes  of  his  condition  on  January  10,  1900. 
Slight  prominence  over  the  seventh  cervical  spine.  No  crepitus  or  false 
motion.  Movements  of  the  neck  performed  freely.  No  disturl)ances 
in  lower  extremity.  Knee-jerks  normal.  The  only  sensory  anomalj^ 
was  a  diminution  in  the  sensibility  to  pain  on  the  inner  surfaces  of 
both  arms.  The  muscles  of  the  forearm  were  weaker  than  normal, 
but  were  not  paralyzed.  There  was,  however,  extensive  paralyses  of 
atrophic  type  (atroi)ln',  fibrillary  twitchings,  lowered  electric  excita- 
bility) in  both  upper  arras  and  both  shoulders.  The  muscles  chiefly 
affected  were  the  deltoid  and  the  supraspinati  and  infraspinati.  Under 
cauterization,  electricitj^,  and  the  iodid  of  potash  the  patient  has  been 
gradually  improving  (January  25th)  and  liis  chances  for  fair!}'  com- 
plete recovery  seem  good.  —  Ed.] 

Intramedullary  hemorrhages  eventuate  in  the  partial 
destruction  of  the  cord-substance  proper,  within  which 
they  originate.  According  to  Wagner  and  Stolper,  the 
accident  is  usually  the  result  of  the  strain  to  which  the 
cord  is  subjected  in  cases  of  sprains  caused  by  overflex- 
ion  of  the  spine.  Paralysis  is  a  prominent  and  charac- 
teristic symptom  of  intramedullary  hemorrhage.  The 
symptoms  mentioned  under  extramedullary  hemorrhage 
may  also  be  in  evidence. 

The  following  points  deserve  special  attention  :  Intra- 
medullary hemorrhages  in  the  cervical  region  down  to 
and  including  the  fourth  segment  cause  death  by  paralysis 


138  DISEASES  CAUSED  BY  ACCIDENTS. 

of  the  phrenic  nerves.  In  tlie  h)wer  cervical  rcii'ion  the 
hemorrhages  canse  paralysis  of  the  brachial  plexus.  In 
the  dorsal  region  hemorrhage  rarely  or  never  occurs 
except  in  connection  with  injuries  of  the  vertebrie. 
Intramedullary  hemorrhages  in  the  luml)ar  region  are,  on 
the  other  hand,  very  frequently  noted,  and  give  rise  to 
the  following  symptoms  :  paralyses  affecting  the  lower 
extremities,  the  i)ladder,  and  the  rectum,  and  disturbances 
of  sensation.  These  symptoms  may  persist  for  a  long 
time. 

5.  SYMPTOMS  OF  INJURIES  OF  THE  SPINAL  CORD. 
A.  Injuries  of  the  Cervical  Region  of  the  Cord. 

Total  transverse  lesions  in  the  cervical  region  are  fatal ; 
death  is  consequent  upon  respiratory  failure  due  to  par- 
alysis of  the  phrenic  nerves.  If  the  lesion  does  not  at 
once  involve  the  whole  diameter  of  the  cord,  death  may 
not  occur  at  once  ;  it  may  follow  secondary  hemorrhage 
or  secondary  injuries  due  to  dislocation  of  the  fragments 
of  bone  in  cases  of  fracture.  On  account  of  the  origin 
of  the  fibers  of  the  phrenic  nerves,  the  most  dangerous 
transverse  lesions  are  those  involving  the  cord  as  far 
down  as  the  fourth  cervical  segment,  inclusive.  In  cases 
of  partial  transverse  lesion  at  this  level  respiration  ceases 
on  the  affected  side ;  that  side  of  the  thorax  does  not 
move,  and  no  breath-sounds  can  be  heard,  while  the  dia- 
j)hragm  lies  higher  than  on  the  normal  side.  A  hypo- 
static pneumonia  is  likely  to  develop. 

Total  transverse  lesions  of  the  fifth  cervical  segment 
are  followed  by  a  comj^lete  loss  of  motor  power  of  all 
the  nniscles  supplied  by  the  brachial  plexus.  In  addi- 
tion to  this,  there  is  paralysis  of  the  centers  below  the 
lesion  ;  reflex  action  is,  therefore,  totally  abolished,  and 
there  is  paralysis  of  sensation  of  the  extremities  and  of 
the  body  up  to  the  level  of  the  second  rib.  It  is  charac- 
teristic of  a  transverse  lesion  of  the  sixth  cervical  seg- 


THE  SPINAL  CORD.  139 

ment  that  the  radial  side  of  the  arm  remains  free  from 
paralysis  as  far  down  as  the  Avrist. 

The  following  symptoms  are  common  to  all  lesions  of 
the  cervical  region  of  the  cord  :  (1)  Vasomotor  distur- 
bances ;  (2)  oculopupillarv  symptoms;  (3)  disturbances 
of  reflex  action. 

The  temperature  may  rise  extremely  high.  In  one 
case  seen  by  AVelier  in  London  it  was  41.1°  C.  shortly 
before  death  ;  and  44°  C.  shortly  after  death,  eight  hours 
subsequent  to  the  accident.  Very  high  temperatures 
(41.0°  and  42.5°  C.)  have  likewise  been  observed  by 
Wagner  and  Stolper.  Other  cases  have  exhibited  a  sub- 
norihal  temperature  and  a  slow  pulse. 

In  respect  to  the  oeulopu[)illary  symptoms,  the  follow- 
ing points  are  to  be  noted  :  If  there  is  paralysis  of  the 
sympathetic,  the  pupil  will  be  found  contracted.  In  case 
of  partial  transverse  lesion,  the  contraction  is  seen  on  one 
side  only,  while  it  affects  both  sides  in  cases  of  total 
transverse  lesion.  The  lids  droop  and  do  not  close  nor- 
mally. There  are  changes  in  the  resistance  of  the  eye- 
balls. Partial  lesions  cause  an  increased  activity  of  the 
sweat-glands  of  one  side  of  the  face.  In  some  cases  of 
injury  to  the  cervical  cord  the  entire  body  is  aifected  by 
hyperidrosis. 

Totid  lesions  of  the  cord  as  far  down  as  tlie  seventh 
cervical  segment  are  followed  by  total  abolition  of  reflex 
action,  including  the  reflexes  of  the  eye. 

The  ra])idity  with  which  death  follows  total  transverse 
lesion  of  the  cervical  cord  depends,  as  before  indicated, 
on  the  level  of  the  injury  :  the  higher  up  the  lesion,  the 
sooner  may  death  be  expected.  In  case  of  injuries  of  the 
lower  part  of  the  cervical  cord,  death  is  usually  to  be 
ascribed  to  the  complications  that  inevital)ly  follow  (par- 
alysis of  respiration ;  vasomotor  j)aralysis ;  hypostatic 
pneumonia ;  paralysis  of  bladder,  rectum,  etc.). 

Lesions  of  the  dorsal  cord  are  invariably  due  to  inju- 
ries of  the  bony  framework — fractures    or    dislocations. 


140  DISEASES  CAUSED  BY  ACCIDENTS. 

Total  transverse  lesions  in  this  region  are  no  less  fatal  ; 
death  may  take  place  soon  after  the  injnry,  or  may  occur 
in  consequence  of  complications  involving  the  bladder  or 
the  lungs.  Partial  transverse  lesions  of  the  dorsal  cord 
may,  even  in  severe  cases,  progress  to  a  fayoral)le  termina- 
tion. It  goes  without  saying  that  the  upper  limit  of  both 
motor  and  sensory  paralyses  in  dorsal  lesions  lies  below 
that  of  similar  lesions  in  tlie  cervical  region.  The  symp- 
toms of  paralysis  following  partial  transverse  lesions  of  the 
dorsal  cord  often  persist  for  a  long  time,  characterizing  the 
case  even  in  its  later  stages.  They  are  as  follows  :  Dis- 
turbances of  sensation  ;  sensitiveness  of  the  spine  or  the 
spinous  processes  ;  distur])anees  of  mobility  of  the  spine, 
frequently  attended  ))y  inability  to  stoop  ;  disturbances  of 
gait. 

The  lumbar  region  of  the  cord  extends  from  about  the 
eleventh  or  twelfth  dorsal  vertebra  down  to  the  first  or 
second  lumbar  vertebra,  where  the  eauda  equina  begins. 
Injuries  of  the  lumbar  cord  are  followed  only  by  par- 
alysis of  the  lower  extremities  and  of  the  bladder  and 
rectum. 

Of  cases  of  unilateral  lesion  it  may  be  stated,  in  gen- 
eral terms,  that  there  is  a  motor  paralysis  on  the  side  of 
the  injury  and  a  sensory  jiaralysis  on  the  opposite  side. 
Special  symptoms  may  be  mentioned  as  follows  : 

1.  Muscular  paralysis  with  atrophy  (curable)  below  the 
level  of  the  lesion. 

2.  Ilise  of  temperature  in  the  paralyzed  extremities. 

3.  Hyperesthesia  in  respect  to  touch,  pain,  heat,  and 
cold. 

4.  Loss  of  muscle  and  pressure  senses. 

5.  Exaggeration  of  the  tendon-reflexes. 

G.  In  unilateral  lesions  involving  the  cervical  cord 
there  is  contraction  of  the  ])U])il  and  drooping  of  the  lid. 

Lesions  of  the  cauda  equina  and  the  conns  terminalis, 
which  occur  as  the  residt  of  fracture,  are  followed  by  : 
anesthesia  of  the  skin  of  the  coccygeal  region  and  of  the 


CONTUSIONS  OF  THE  SPINE.  141 

region  of  the  anus  and  external  genitals  ;  impotence  ;  and 
paralysis  of  the  bladder  and  rectum. 

The  same  symptoms,  however,  a[)pear  in  "cases  of  injury 
of  the  lumbar  plexus  or  of  the  sacrococcygeal  plexus. 

B.  Injuries  of  the  Spine. 

Statistics. — ^Nly  ol)servations  cover  151  cases  of  injury 
of  the  vertebral  column.  The  cervical  region  was  involved 
in  28  cases,  the  dorsal  region  in  65,  and  the  lumbar  region 
in  58.  My  cases  of  injury  of  the  spinal  column,  includ- 
ing those  of  injury  of  the  cord,  amount  to  2.96  fo  of  all  the 
cases  of  traumatism  that  came  under  my  observation.  Ac- 
cording to  Wagner  and  Stolper,  out  of  70,393  cases  of 
traumatism  the  spine  was  involved  in  only  50(3,  or  in 
0.71  fo-  Of  my  151  cases  there  were  62  contusions  and 
sprains  and  39  fractures  and  dislocation-fractures.  AVag- 
ner  and  Stolper  cite  136  cases  of  fracture,  including  dis- 
location-fractu  res. 

I.  Contusions  of  the  Spine. 

Contusions  of  the  spine  vary  greatly  in  eifect  according 
to  their  location,  intensity,  and  nature.  Light  cases  of 
contusion  may  give  rise  to  no  symptoms  at  all,  and  necessi- 
tate no  interval  of  rest  from  work.  In  some  cases  there 
is  pain  in  the  spine  and  inability  to  stoop,  although  nothing 
abnormal  can  be  detected  on  examination.  In  other  cases, 
especially  when  the  spine  is  struck  at  a  tangent,  we  may 
observe  the  development  of  a  tumor,  over  which  a  coarse 
desquamation  takes  place.  This  condition  has  been  called 
"decollement  tramati(iue"  by  the  French,  and  "menin- 
gocele spuria  traumatica"  by  some  German  writers.  Wag- 
ner and  Stolper  do  not  accept  the  theory  of  a  connection 
between  these  cystic  tumors  and  the  subdural  space.  At 
any  rate,  no  serious  prognosis  attaches  to  them.  Lininger, 
who  has  given  the  subject  much  attention,  states  that  the 
prognosis  is  favorable,  since  the  spinal  cord  is  not  involved. 
The  condition  can  be  cured  by  tapping.  The  symptoms  are 


142  DISEASES   CAUSED  BY  ACCIDENTS. 

as  follows  :  Pain  in  the  Inmbar  region,  disturbances  of 
mobility  of  the  spine,  pain  radiating  toward  the  lower 
extremities,  and  sometimes  paralyses  in  the  latter. 

Contusions  may  also  cause  intradural  and  extradural 
hemorrhages,  sprains,  fractures,  and  dislocations  of  the 
spine.  They  are  sometimes  followed  by  severe  inflamma- 
tions of  the  cord-substance. 

Fracture  of  the  sacrum,  with  tesion  of  the  Cauda  equina.  Sequel, 
extreme  degree  of  incapacity  lor  selt'-support. 

A  man,  thirty-five  years  of  age,  fell  from  a  lieight  of  twenty-eight 
feet.  He  was  discharged  from  tlie  hospital  in  three  weeks.  On  ex- 
amination of  the  patient,  who  was  a  rather  large,  poorly  nourished 
mail,  I  found  the  sacrum  thickened,  while  the  muscles  of  the  leg  and 
the  small  muscles  of  the  foot  were  paralyzed  and  flaljby.  There  was 
difficulty  of  urination  and  defecation,  and  impotence.  His  gait  was 
spastic-ataxic  ;  he  walked  with  a  cane.     Insurance  allowance,  HQ'ifo. 

Case  of  severe  contusion  of  the  dorsal  region,  complicated  by  "('o«r«.s- 
sion  of  the  cord  "  (dislocation-fracture?),  and  fracture  of  ribs  on  the  left 
side.     Sequel,  diftuse  chronic  myelitis.     Death  in  three  years. 

A  carpenter,  thirty-three  years  of  age,  fell  from  a  scaffolding 
eight  feet  high  on  December  i;},  1892,  striking  with  his  back  on  a 
beam.  He  was  treated  at  home,  where  he  lay  in  bed,  partly  on 
account  of  a  sprained  ankle.  I  examined  him  April  26,  1898.  He  was 
a  rather  large  man,  of  vigorous  build  and  pale  complexion.  He  wore 
an  expression  of  depression.  He  appeared  to  find  difficulty  in  sup- 
porting the  upper  part  of  his  body.  He  walked  with  a  shuffling  gait, 
especially  noticeable  on  the  right  side.  The  dorsal  spine  was  curved 
to  the  left,  l)eginning  at  the  sixth  dorsal  vertebra  ;  the  spine  was  pain- 
ful from  tliat  point  all  the  way  down.  The  sixth  and  seventh  ribs  on 
the  left  side  were  perceptibly  thickened  in  the  anterior  axillary  line 
and  were  painful  on  pressure.  The  reflexes  of  the  trunk  were  exag- 
gerated ;  on  the  left  side  the  patellar  reflex  was  apparently  lost ;  on  the 
right  side  it  was  present,  Itut  was  extremely  weak.  Sensibility  on  the 
leftside  of  the  l)ody  was  distinctly  diminished  below  the  level  of  the 
spinous  i)rocess  of  the  sixth  dorsal  vertel)ra.  The  left  lower  extremity 
was  considerably  atrophied.  Tlie  mobility  of  the  .spine  was  greatly 
diminished. 

Treatment. — Massage  of  the  back,  but  without  any  effect;  the 
condition  of  the  patient  gradually  grew  worse. 

Suhsequent  Symptoms. — Atrophy  of  the  left  side  of  the  face,  conjunc- 
tivitis, jaundice,  contracted  pupils,  loss  of  pupillary  reflex,  interco.stal 
neuralgia,  girdle  sensation,  lancinating  i)ains  radiating  toward  the 
thighs,  and  cystitis.  The  patient  found  walking  more  and  more 
difficult.  On  November  2fi,  1H9.i.  he  was  taken  to  a  hospital.  On 
catheterization  25.50  gm.  of  urine  were  drawn.  Sensibility  was 
greatly  diminished  ;  the  patellar  reflexes  were  exaggerated.  Fever  was 
present  and  the  urine  contained  considerable  albumin.    Death  occurred 


CONTUSIONS  OF  THE  SPINE.  143 

December  14,  1895,  with  symptoms  of  heart  failure.  Postmortem 
examiuatiou  showed  multiple  myelitis,  dilatation  of  the  left  ventricle 
of  the  heart,  nephritis,  and  cystitis. 

Case  of  severe  contusion  {fracture?)  of  the  tenth  and  eleventh  dorsal 
vertebrse,  complicated  by  "  concussion  of  the  cord." 

Sequel,  complete  incapacity  lor  self-support  in  consequence  of  a 
traumatic  myelitis. 

A  mason,  thirty -eight  years  of  age,  fell  on  August  4,  1890,  from 
a  flight  of  steps  about  eight  feet  high,  striking  on  his  loins.  He 
was  treated  in  hospital  for  three  weeks  ;  subsequently  at  home  by  in- 
unctions and  baths.  I  examined  him  November  3,  1890.  He  was  a 
man  of  middle  size  and  of  pale  complexion.  The  spinous  processes 
of  the  tenth  and  eleventh  dorsal  verteV)r8e  were  somewhat  thickened  ; 
the  spine  was  painful  to  pressure  below  the  spinous  process  of  the  sixth 
dorsal  verteljra  and  was  greatly  limited  in  mobility.  The  body  was 
held  stiffly  ;  the  gait  was  spastic-ataxic  ;  and  walking  was  very  diffi- 
cult. All  the  reflexes,  especially  those  of  the  left  side,  w^ere  exagger- 
ated. The  patient  was  impotent.  Tliere  was  retardation  of  urination 
and  of  defecation,  the  latter  always  being  very  painful.  The  condi- 
tion of  the  patient  has  remained  unchanged  up  to  date. 

Ca.se  of  fracture  of  the  skull,  contusion  of  the  cervical  region  of  the 
spine,  and  concussioiiof  the  cord. 

A  mason,  thirty  years  of  age,  fell  from  a  scaftblding  fifteen  to 
eighteen  feet  high  on  May  4,  1896.  He  was  unconscious  after  the  acci- 
dent and  remained  so  until  he  was  taken  to  the  hospital.  Very  few 
data  are  obtainable  for  this  period  ;  during  the  first  few  days  the  urine 
is  said  to  have  been  bloody.  I  examined  him  August  5,  1896.  He 
was  a  large,  vigorous  man  ;  there  was  a  small  scar  and  depression  on 
the  left  ]iarietal  bone  ;  the  spinous  process  of  the  third  cervical  ver- 
tebra was  perceptildy  thickened,  as  were  also  the  spinous  processes  of 
the  sixth  and  seventh  dorsal  vertebra?.  The  latter  were  very  sensi- 
tive to  pressure.  The  left  pupil  was  dilated  and  reacted  slowly  ;  the 
pulse  was  increased  in  rapidity.  The  spine  was  held  fixed  on  every 
attempt  at  motion.  On  November  6,  1H96,  he  was  allowed  30% 
insurance.  He  was  at  that  time  perceptibly  improved  also  in  respect 
to  external  signs.  Later  he  was  allowed  66.66^  insurance  on  the 
ground  of  a  traumatic  neurasthenia. 

Incomplete  fractures  of  the  vertebrse  may  be  caused 
indirectly  by  a  contusion  acting  in  the  long  axis  of  the 
spine — by  a  fall  on  the  buttocks  or  the  feet,  for  instance, 
or  when  the  head  is  struck  by  falling  objects.  Contusions 
of  the  spine  have  the  least  favorable  prognosis  when  the 
cervical  region  is  involved  ;  the  consequences  may,  how- 
ever, be  no  less  serious  in  case  of  contusions  of  the  dorsal 
region. 

Serious  consequences  may   follow  such  injuries  as  the 


144 


DISEASES   CAUSED  BY  ACCIDENTS. 


incomplete  fractures  just  mentioned  or  contusions  due  to 
blows  on  the  spine  or  to  kicks  on  the  shoulder  or  neck, 
etc.  The  cancellous  tissue  of  the  vertebrae  remains  soft 
for  a  long  time  after  fractures,  complete  or  incomplete, 
sometimes  eontiuuing  so  almost  for  one  year.  The  injury 
may  at  first  give  rise  to  no  symptoms  whatever,  especially 


Fig.  7. 


Fig.  8. 


when  the  patient  lies  quietly  in  bed.  When  he  begins  to 
walk  again,  however,  the  weight  of  the  body  causes  the 
gradual  development  of  an  angular  curvature,  which 
causes  more  and  more  pain  (Kiimmel's  disease)  (spon- 
dylytis  traumatica).  The  kyphosis  may  be  very  slightly 
marked  or  very  aj^parcnt.  For  the  early  treatment  of  the 
injury  Kummel  recommends  rest  in  bed,  with  extension 


SPRAINS   OF  THE  SPINE.  145 

applied  to  the  head.  Later,  when  tlie  patient  begins  to 
walk,  he  is  to  w'ear  a  sujiporting  ajiparatus  (corset,  etc.). 
These  cases  run  a  very  chronic  course,  partly  because  of 
the  softened  condition  of  the  cancellous  tissue,  partly  because 
of  the  very  slow  absorption  of  the  crushed  intervertebral 
discs. 

In  addition  to  the  deformity  of  the  spine,  the  symptoms 
are  as  follows  :  compression  neuritis,  due  to  the  narrow- 
ing of  the  intervertebral  foramina,  exaggerated  reflexes, 
neurasthenic  disturbances,  psychic  depression,  etc.  The 
degree  of  incapacity  for  self-support  varies  greatly  in 
different  individuals,  depending  on  the  intensity  of  the 
symptoms. 

A  case  of  contusion  of  the  neck.  Sequel,  tuljerculosis  of  the  cervical 
vertebrae.     Death. 

A  niasou,  fifty-four  years  of  age,  fell  headlong  from  a  scaffolding 
about  ten  feet  high  ou  the  17th  of  May,  1895,  striking  on  the  back 
of  hi.s  neck.  He  was  unconscious  for  a  short  time.  He  was  taken 
home  and  lay  in  bed  for  four  weeks,  receiving  only  medicinal  treat- 
ment. He  had  the  feeling  after  his  tall  of  having  "  iiroken  his  neck." 
He  entered  my  hospital  August  3,  189.5.  He  was  a  rather  large,  thin, 
poorly  nourished  man.  Until  the  accident  lie  is  said  to  have  been 
perfectly  liealthy  and  ".straight  as  a  board."  The  patient  complained 
of  headache,  vertigo,  pain  in  the  neck  the  lumbar  region,  l)etween  the 
shoulder-bhides,  and  on  movement  of  the  head.  On  examination  I 
found  a  sharp  angular  curvature  at  the  junction  of  the  neck  with  the 
dorsal  spine.  The  wliole  cervical  region  of  the  spine  was  very  sensi- 
tive to  pressure  ;  movement  of  the  head  was  difficult.  When  lying  in 
bed,  it  was  necessary  to  place  a  support  under  the  head.  On  looking 
at  the  patient  from  the  front  tlie  neck  appeared  to  be  sunk  into  the 
body.  Tlie  arm-reflexes  were  exaggerated.  The  pulse  was  more  rapid 
than  normal.  The  patient  was  discharged  on  October  19,  1895,  with  an 
insurance  allowance  of  100%.    He  died  April  18,  1897,  of  tuberculosis. 

2,  Sprains  of  the  Spine. 

Sprains  are  caused  by  the  same  forces  that  produce  di.s- 
locations ;  their  action  is,  how" ever,  not  carried  so  far. 
Violent  movements  of  flexion,  extension,  rotation,  or 
lateral  flexion  are  the  factors  concerned  in  these  cases. 
Although  the  process  stops  short  of  dislocation,  capsules 
and  ligaments  are  often  torn  and  pieces  of  bone  may  be 
10 


146  DISEASES   CAUSED  BY  ACCIDENTS. 

broken  oif — bits  of  the  oblique  processes,  for  instance. 
It  is  very  important  to  remember  that  sprains  of  the 
cervical  region  of  the  spine  may  cause  death  by  com- 
pression of  the  cord.  Fatal  results  are  observed  only 
when  the  cervical  spine  is  involved,  which,  in  consequence 
of  its  great  flexibility,  is  exposed  to  an  extreme  degree  of 
torsion.  Sprains  are  almost  out  of  the  question  in  the 
dorsal  region,  certainly  between  the  first  and  the  tenth 
dorsal  vertebrae.  They  may,  however,  take  place  in  the 
articulations  between  the  transverse  processes  and  the  ribs, 
or  between  the  ribs  and  the  bodies  of  the  vertebne,  caus- 
ing lacerations  of  ligaments  and  capsules. 

Sprains  are  more  likely  to  occur  in  the  lumbar  region 
than  in  the  dorsal,  but  fatal  cases  are  practically  excluded. 
We  will  refer  here  to  only  one  form  of  sprain  in  the  lum- 
bar region,  which  is  of  rare  occurrence.  It  involves  the 
oblique  processes  of  the  fifth  lumbar  vertebra  and  those 
of  the  sacrum  in  the  lumbosacral  fossa.  In  extension  of 
the  spine  the  two  oblique  processes  glide  backward  in  the 
lumbosacral  fossa.  Sudden  or  violent  overextension  may 
cause  a  laceration  of  ligaments  or  capsules  at  this  jwint. 
The  injury  leads  to  extravasation  of  blood  and  gives  rise 
to  pain,  which,  although  never  very  severe,  may  interfere 
with  stooping. 

Sj)rains  that  involve  the  spine  in  its  whole  length  may 
give  rise  to  strains  of  the  cord,  followed  by  severe  symp- 
toms at  first.  The  prognosis  is,  however,  usually  favor- 
able. 

The  diagnosis  of  a  sprain  always  involves  some  diffi- 
culty, which  increases  with  the  time  that  has  elapsed  since 
the  accident.  AVhen  we  find  that  the  spinous  processes 
and  lateral  parts  of  the  vertebrae  are  in  normal  positions, 
and  that  no  anatomic  changes  can  be  determined,  we  are 
able  to  exclude  fracture  and  dislocation,  and,  in  connec- 
tion with  the  following  symptoms,  to  make  a  diagnosis 
of  sprain  :  a  stiff  way  of  holding  the  body  ;  rigidity  of 
the  muscles  of  the  back  ;  fixation  of  the  spine  on  move- 


A  TEXT-BOOK  OF  EMBRYOL- 
OGY. By  John  C  Heisler,  M.D., 
Professor  of  Anat- 
omy in  the  Medico- 
Chirorgical  CoIIegfe, 


HEISLER'S 
EMBRYOLOGY 


Philadelphia.  Octavo  volume  of  405 
pages,  with  190  illustrations,  26  in 
colors.    Cloth,  $2.50  net. 

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recent  years  such  great  interest  in  connection 
with  the  teaching  and  with  the  proper  compre- 
hension of  human  anatomy,  it  is  of  first  im- 
portance to  the  student  of  medicine  that  a  con- 
cise and  yet  sufficiently  full  text-book  upon  the 
subject  be  available.  It  was  with  the  aim  of 
presenting  such  a  book  that  tliis  volume  was 


"  The  book  is  written  to  fill  a  want  which  has  dis- 
tinctly existed  and  which  it  definitely  meets;  com- 
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to  anything." — Medical  News,  New  York. 


written,  the  author,  in  his  experience  as  a 
teacher  of  anatomy,  having  been  impressed 
with  the  fact  that  students  were  seriously  handi- 
capped in  their  study  of  the  subject  of  embry- 
ology by  the  lack  of  a  text-book  full  enough  to 
be  intelligible,  and  yet  without  that  minuteness 
of  detail  which  characterizes  the  larger  treatises, 
and  w^hich  so  often  serves  only  to  confuse  and 
discourage  the  beginner.       ^     ^     ^     Ji     ^ 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
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A  MANUAL  OF  DISEASES  OF 
THE  EYE.  By  Edward  Jackson, 
A.M.,  M.D.,  for- 
merly Professor  of 
Diseases  of  the  Eye 
in  the  Philadelphia 


JACKSON  ON 
DISEASES  OF 
THE  EYE 


Polyclinic  and  College  for  Graduates 
in  Medicine.  t2mo,  604  pages,  with 
J  78  illustrations  from  drawings  by  the 
author.    Cloth,  $2.50  net. 

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This  book  is  intended  to  meet  the  needs  of  the 
general  practitioner  of  medicine  and  the  begin- 
ner in  ophthalmology.  More  attention  is  given 
to  the  conditions  that  must  be  met  and  dealt 
with  early  in  ophthalmic  practice  than  to  the 
rarer  diseases  and  more  difficult  operations  that 
may  come  later.  ^  ^  ^  ,^  ^  ^  ^ 
It  is  designed  to  furnish  efficient  aid  in  the 
actual  work  of  dealing  w^ith  disease,  and  there- 
fore gives  the  place  of  first  importance  to  the 
recognition  and  management  of  the  conditions 
present  in  actual  clinical  work.  For  practitioners 
in  other  departments  of  medicine  and  surgery, 
the  most  important  phase  of  ophthalmology  is 
that  of  the  relations  of  ocular  symptoms  and 
lesions  to  general  diseases.  A  special  chapter 
is  devoted  to  these  relations,  and  the  references 
it  contains  will  put  the  reader  in  touch  with  the 
related  facts  in  all  the  preceding  chapters.  ^   <^ 

For  sale  by  all  Booksellers,  or  sent  post-paid  on 
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DISLOCATIONS  OF  THE  SPIXE.  147 

ment  of  the  l)otly  ;  and  pain.  The  pain  may  be  more 
severe  than  in  cases  of"  dislocation,  and  may  persist  for  a 
long  time.  There  may  be  a  considerable  degree  of  inca- 
pacity for  self-snpport,  especially  if  neurasthenic  distur- 
bances manifest  themselves. 

3.  Dislocations  of  the  Spine. 

For  anatomic  reasons  dislocations  are  most  likely  to 
occur  in  the  cervical  region  ;  they  occur  nuich  less  fre- 
quently in  the  lumbar  spine,  and  very  rarely  in  the  dorsal 
region.  Leaving  aside  the  special  conditions  attaching  to 
the  odonto-atloid  articulation,  it  will  suffice  to  bear  in 
mind  that  dislocations  of  the  first  four  cervical  vertebrae 
may  cause  immediate  death  by  reason  of  paralysis  of  the 
phrenic  nerve. 

Dislocations  of  the  cervical  vertebrae  are  in  many  cases 
not  pure  dislocations,  but  dislocation-fractures,  the  bodies 
or  processes  suffering  fracture  at  the  time  of  injury. 

Dislocations  of  the  cervical  vertebrae  may  be  classified 
as  follows  :  (1)  Forward  dislocations,  or  flexion-disloca- 
tions ;  (2)  backward  dislocations,  or  extension-disloca- 
tions ;  (3)  lateral  dislocation ;  (4)  dislocation  by  rotation. 

The  first  form  may  be  directly  or  indirectly  caused  by 
overflexion — by  violence  applied  to  the  neck  in  the  one 
case  ;  by  falls  on  the  head,  face,  etc.,  in  the  other.  It  is 
possible,  also,  for  a  forward  dislocation  to  be  produced  by 
overextension.  It  is  exceedingly  important  for  our  pur- 
poses to  bear  in  mind  that  dislocations  of  the  cervical 
vertebrae  may  also  be  caused  by  muscular  action.  Accord- 
ing to  Wagner  and  Stolper,  dislocations  by  rotation  not 
infrequently  occur  in  this  manner.  We  are  not  concerned 
here  with  the  cases  involving  serious  injuries  of  the  cord, 
or  with  those  that  terminate  fatally,  but  rather  with  those 
in  which  recovery  may  be  expected,  with  or  without  con- 
sequent deformity. 

Even  when  properly  reduced,  and  showing  no  external 
deformity,  dislocations  are  very  likely  to  cause  the  head 


148  DISEASES  CAUSED  BY  ACCIDENTS. 

or  neck  to  be  held  in  a  somewhat  unnatural  ])osition  for  a 
long  time  after  recovery.  The  head  is  inclined  forward, 
especially  after  forward  dislocations  ;  this  position  may  be 
maintained  for  a  long  time  or  even  permanently.  An  ab- 
normal position  of  the  head  is  always  observed  in  case  of 
dislocation-fractures,  or  when  the  displacement  was  not 
properly  reduced.  The  following  schema,  arranged  l)y 
Wagner  and  Stolper,  is  very  useful  in  diagnosing  tlie  dis- 
locations of  the  cervical  vertebrae  from  the  abnormal  posi- 
tion of  the  head  observed  after  recovery  : 

Dislocations  by  Rotation. 

I.  Rotation  to  the  right. 

1.  With  the  left  articular  processes  in  contact  at  their 

extremities  : 

(a)   The  head  is  inclined  to  the  right. 

(6)  The  sj)inous  process  of  the  dislocated  vertebra 
is  slightly  displaced  to  the  left. 

(c)  The  left  transverse  process  is  slightly  promi- 
nent. 

(<^/)  If  palpable  on  pharyngeal  examination,  the 
body  of  the  dislocated  vertebra,  especially 
its  left  side,  is  felt  to  be  slightly  displaced 
forward. 

2.  With  complete  displacement  of  the  left  articular 

processes : 
(a)  The  head  is  inclined  to  the  left. 
(6)   The  spinous  process  of  the  dislocated  vertebra 

is  markedly  displaced  to  the  left. 
{(■)    The  left  transverse  process  is  decidedly  promi- 
nent, 
(r/)  On  pharyngeal  examination  the  left  side  of  the 
body  of  the  dislocated  vertebra  is  felt  to  be 
displaced  forward. 
II.   Rotation  to  the  left. 

The  conditions  just  described  are  reversed. 


DISLOCATIONS  OF  THE  SPINE. 


149 


Dislocation 

BY  Flexion. 

Dislocation  by  Rotation. 

Incomplete, 

with   the  Ar- 

Incomplete. 

Complete. 

ticular      Pro- 
cesses in  Con- 
tact at  Their 
Edges. 

Complete. 

Head, 

Inclined     for- 

Inclined     for- 

Inclined later- 

Inclined  later- 

ward. 

ward  or  back- 

ally and  away 

ally,    and    to- 

ward. 

from  the  side 
of  the  dislo- 
cated  articu- 
lar processes. 

ward  the  side 
of  the  dislo- 
cated articu- 
lar processes. 

Neck, 

Appears  length- 

Shortened. 

May    show    a 

Crease  on   side 

ened. 

crease  on  side 
of    the     dis- 
placed articu- 
lar processes. 

of  fixed  artic- 
ular jirocesses. 

Spinous  pro- 

cesses  

Separated  ;  not 

Not  separated  ; 

Displaced  later- 

Same. 

displaced  lat- 

not displaced 

ally  and  away 

erally. 

laterally. 

from    side  ol 
dislocated  ar- 
ticular    pro- 
cesses. 

Transverse  pro- 

cess,    .... 

.Slightly  prom- 

Decidedlyproui- 

Prominent   on 

Decidedlyprom- 

inent  on  both 

iiieiit  on  both 

side  of   non- 

inent  on  side 

sides. 

sides. 

displaced   ar- 
ticular    pro- 
cesses. 

of  fixed  artic- 
ular processes. 

Body     of     the 

vertebra.    .   . 

Slightly  prom- 

Decidedly prom- 

Slightly promi- 

Decidedly prom- 

inent. 

inent. 

nent,  especial- 
ly on  side  of 
n  on  displaced 
articular  pro- 
cesses. 

inent  on  same 
side. 

Even  after  successful  reduction  we  often  meet  with 
jjaralysis,  malposition  of  the  head,  diminished  mobility,  and 
crepitation  for  some  time  subsequent  to  the  injury.  These 
disadvantages  can  be  largely  overcome  by  massage  and 
gymnastics. 

Dislocations  of  the  dor.sal  vertebrae  are,  as  already 
stated,  very  unusual  accidents,  and  probably  are  always 
associated  with  fractures. 

The  conditions  obtaining  in  the  lumbar  region  are  more 
favorable  to  the  occurrence  of  dislocations,  but  even  here 


150  DISEASES   CAUSED  BY  ACCIDENTS. 

they  are  only  observed  in  cases  of  very  severe  traumatism 
directly  applied  to  the  spine,  and  then  usually  in  the  form 
of  dislocation-fractures. 

When  the  injury  involves  the  cord,  we  have  the  various 
symptoms  already  described. 

4.  Fractures  of  the  Vertebrae. 

As  in  all  cases  of  injury  of  the  spine,  the  chief  danger 
in  fractures  is  involvement  of  the  cord.  We  must  not 
concern  ourselves  here  with  cases  of  total  transverse 
lesions,  in  which  death  occurs  immediately  or  soon  after 
the  accident ;  they  have  already  been  sufficiently  dis- 
cussed for  our  purposes.  Our  interest  lies  in  fractures 
causing  only  partial  transverse  lesions,  or  lesions  of  any 
kind  followed  by  recovery  and  involving  the  future  health 
of  the  patient. 

The  disturbances  of  function  caused  by  injury  to  the 
cord  do  not  always  bear  an  exact  relation  to  the  severity 
of  the  lesion.  Fractures  attended  by  serious  lesions  of 
the  cord  may,  for  example,  have  a  favorable  outcome, 
while  cases  in  which  the  injury  to  the  spine  is  slight  or 
difficult  of  diagnosis,  with  no  sign  of  involvement  of  the 
cord,  may  be  followed  Ijv  grave  functional  disorders  and 
a  high  degree  of  incapacity  for  self-su})port. 

Fracture  of  the  spine  is,  on  the  whole,  a  rare  accident ; 
it  is  encountered,  however,  with  relative  frequency  in 
certain  industries.  Bruns  estimates  its  proportion  to 
fractures  in  general  at  0.4^,  while  Wagner  and  Stol^ser, 
in  a  series  of  observations  extending  over  twenty  years, 
found  it  in  2.07  fo  of  fracture-cases.  These  statistics  of 
the  latter  authors  are  based,  however,  on  accidents  occur- 
ring in  the  coal-mines  of  upper  Silesia,  and  conditions 
favorable  to  s})inal  fracture  are  found  preeminently  in 
this  industry,  with  its  many  opportunities  for  falls  from  a 
height,  cavings-in,  and  the  falling  of  masses  of  coal  or 
rock  on  the  miners  when  they  are  stooping  over.  Quarry- 
men  and  all  classes  of  workmen  employed  in  the  building 


FRACTURES  OF  THE   CERVICAL    VERTEBRA.       151 

trades  are  exposed  to  similar  dangers.  In  the  latter 
trades,  35^  of  all  accidents  are  caused  by  falls  from 
more  or  less  high  places,  and  from  18  to  25^  by  blows 
from  falling  oljjects.  These  figures  sufficiently  indicate 
the  danger  of  spinal  injury  in  such  employments. 

In  my  own  series  of  cases  injuries  of  the  spine  amounted 
to  3^  and  fractures  of  the  spine  to  1.5^  of  the  total 
number  of  accidents. 

Fractures  of  the  spine  are  usually  the  result  of  indirect 
violence,  such  as  falls,  striking  on  the  feet  or  buttocks,  or 
blows  from  falling  objects  received  when  stooping,  causing 
overflexion,  or  blows  from  falling  ol)jects  received  on  the 
head  or  slioulders.  There  are  exceptional  cases,  however, 
as  we  shall  see  later  on,  in  which  fracture  is  due  to  direct 
violence.  Fracture  may  be  caused  by  muscular  action, 
but  such  an  accident  is  usually  to  be  explained  by  a  dis- 
eased condition  of  the  bone  consequent  upon  syphilitic  or 
tubercular  inflammation,  etc. 

For  anatomic  reasons  it  will  be  advisable  to  discuss 
fractures  as  they  occur  in  the  three  main  divisions  of  the 
spine  respectively.  In  addition,  I  shall  refer  separately 
to  the  lesion  as  it  affects  the  atlas  and  axis,  since,  because 
of  their  union  through  the  odontoid  process,  they  are  more 
closely  connected  than  any  other  two  vertebrae,  forming  a 
unit  in  respect  to  fnnctional  action. 

Fractures  of  the  Cervical  Vertebrae. 

These  fractures  are  classified  as  follows  :  (1)  Fracture 
of  the  body  ;  (2)  fracture  of  the  laminse ;  (3)  fracture  of 
the  processes. 

Class  3  is  subdivided  into  :  (fi)  Fracture  of  the  spinous 
processes  ;  (6)  fracture  of  the  transverse  processes  ;  (e)  frac- 
ture of  the  oblique  processes. 

The  various  forms  of  fracture  of  the  bodies  and  laminae 
will  be  referre<l  to  later  on. 

In  the  atlas  we  meet  with  transverse  fractures  of  the 
ring,    and    with    fractures    of    the    transverse    processes. 


152 


DISEASES   CAUSED   BY  ACCIDENTS. 


PLATE  8. 

Case  of  Healed  Fracture  by  Rotation  of  the  Third  Cervical 
Vertebra  and  of  the  Corresponding  Spinous  Process. 

The  head  is  slightly  turned  to  one  side.  The  colored  illiistiation 
shows  the  forward  iucliuatiou  of  the  head  and  the  swollen  appearance 

of  the  neck  (which  has 
persisted  up  to  the  pres- 
ent time). 

A  111  a  s  o  n  ,  forty- 
three  years  of  age,  fell 
from  a  ladder  from  the 
height  of  ahout  Ij 
stories,  on  August  8, 
1893.  It  is  not  known 
in  what  manner  he 
struck  the  ground.  He 
Avas  treated  for  seven 
Aveeks  in  the  hospital 
and  for  six  months 
afterward  in  my  clinic, 
receiving  lull  insurance 
allowance  during  that 
time.  He  then  re- 
sumed work,  but  treat- 
ment by  massage  and 
gymnastics  was  con- 
tinued. The  cord  had 
not  been  injured,  and 
the  only  difficulty 
manifested  was  dimin- 
ished mobility  of  the 
head.  At  fir.st  it  could 
be  neither  flexed  nor  extended,  while  lateral  flexion  and  rotation  were 
limited.  Percussion  of  the  spinous  processes  of  the  cervical  vertebrae 
caused,  reflexly,  an  immediate  elevation  of  the  shoulders. 

In  the  course  of  time  the  patient  was  able  to  perform  all  tlie  duties 
of  his  trade.  The  accompanying  illustration  (Fig.  9)  shows  the  slight 
rotation  of  the  head  to  the  left  and  the  apparent  shortening  of  the 
neck  on  the  left  side. 

Insurance  allowance  :  for  first  eight  months,  100%  ;  for  the  follow- 
ing six  months,  50'^  ;  for  one  year  afterward,  'i^fc  ;  since  that  time, 
15%. 


Fig.  9. 


Wagner  and  Stolper  cite  a  case  observed  by  B.  PliilHpps, 
in  which  the  ring  of  the  atlas  was  transversely  l)roken, 
the  anterior  arch,  together  with  the  odontoid  process,  being 
displaced  forward,  without  causing  injury  to  the  cord.    If 


Tah.H. 


/ 


LUh.AnM  F.  Rpidthcld .  Muiirheii 


FRACTURES  OF   THE   CERVICAL    VERTEBRJU.       153 

the  atlas  has  a  spinous  process,  it  may  be  fractured  by 
extreme  degrees  of  flexion  of  the  neck.  However,  frac- 
tures of  the  atlas  are,  on  the  whole,  very  rare  accidents. 
The  axis  may  be  fractured  in  any  of  its  parts.  The 
odontoid  process  is  invariably  fractured  in  case  of  forward 
dislocation  of  the  atlas. 

A  carpenter,  sixty-seven  years  of  age,  fell  from  a  scaffolding  nine 
feet  high  on  the  17th  of  April,  1897,  receiving  the  following  injuries  : 
dislocation  of  tlie  left  clavicle  at  its  sternal  articulation,  concussion  of 
the  brain,  incomplete  rotatory  dislocation  of  the  second  cervical  ver- 
tebra to  the  left.  The  cord  was  not  injured.  The  patient  was  uncon- 
scious for  several  hours. 

He  was  treated  at  home  for  about  four  months,  lying  in  bed  for 
three  weeks.  He  is  said  to  have  walked  very  little  subsequently.  He 
entered  my  hospital  August  7,  1897. 

Subjective  Sijinpfoms. — Rigidity  of  the  neck,  inability  to  move  the 
same.  The  mobility  of  the  shoulder  was  very  limited  and  the  left  arm 
was  almost  useless. 

The  patient  appeared  somewhat  feeble  ;  his  head  was  held  rather 
stiffly  aud  was  slightly  inclined  forward,  the  chin  being  turned  a  little 
to  the  right,  while  the  left  ear  was  slightly  lower  than  the  right.  The 
spinous  process  of  the  second  vertebra  was  distinctly  rotated  to  the 
left.  Rotation  of  the  head  was  very  limited  and  painful :  anteflexion 
caused  no  difficulty,  but  retroflexion  was  impossible.  The  muscles  of 
the  left  side  of  the  neck  were  flahby.  Pressure  on  the  spinous  process 
of  the  axis  gave  rise  to  pain  and  to  a  (juick  movement  of  extension. 
The  patient  was  discharged  November  27,  1897.  At  that  date  the 
head  was  held  straight  aud  could  he  moved  in  all  directions  without 
pain.  Otherwise,  the  condition  as  previously  described  remained  un- 
changed.    The  insurance  allowance  was  reckoned  at  45%. 

Case  of  healed  (Ushication  fracture  of  the  fourth  cervical  vertebra,  com- 
plicated by  injury  of  the  cord,  laceration  of  the  Ugamentum  nuchse,  and 
fracture  of  the  spinous  process  of  the  third  cervical  vertebra.  The  frac- 
ture was  caused  by  overflexion.    The  nasal  bones  were  also  broken. 

A  mason,  forty-nine  years  of  age,  fell  from  a  scaffolding  on 
November  3,  1886,  stiiking  on  his  no.se  and  turning  a  somersault, 
which  caused  overflexion  of  the  neck.  At  the  hospital  a  diagnosis 
was  made  of  intramedullary  hemorrhage.  There  was  paralysis,  both 
motor  and  sensory,  of  all  the  extremities.  I  examined  the  patient 
two  years  later.  He  had  grown  very  old  in  appearance  and  held  his 
head  inclined  forward,  as  shown  in  the  accompanying  illustration. 
(Fig.  10.)  The  spiuons  ])rocess  of  the  fifth  cervical  vertebra  was  very 
prominent.  Just  below  the  third  s])inous  process  there  was  a  depres- 
sion, and  a  little  below  this  could  be  felt  an  elastic,  cord-like  object, 
which  could  be  pushed  into  the  depression.  On  percussion  of  the 
cervical  region  of  the  spine  witli  the  percussiou-hammer  the  shoulders 
were  elevated  with  lightning-like  rajjidity,  while  the  head  was 
thrown  backward.     The  mobility  of  the  head  was  limited  ;  there  was 


154 


DISEASES  CAUSED  BY  ACCIDENTS. 


uo  paralysis.  The  tijis  of  the  fingers  were  affected  by  paresthesia. 
Early  in  1898  I  took  an  X-ray  jihotograpli,  by  which  the  diagnosis  was 
confirmed.  The  insurance  allowance  was  100%  for  one  year;  then 
50%,  and  later,  15%,  when  the  patient  resumed  regular  work.  It 
had  to  1)0  raised  to  50%  later  on,  and  remained  at  that  figure  until 
his  death,  which  occurred  in  May,  1899,  from  pulmonary  tuberculosis. 
There  had  been  uo  improvement  in  the  position  or  mobility  of  his  head. 


Fig.   10. 

According  to  Wagner  and  Stolper,  fractures  of  the 
spinous  process  and  laminae  of  the  axis  are  always  due  to 
direct  violence.  Fractures  of  the  l)ody  or  laminffi,  or  of 
the  odontoid  process,  are  exceedingly  dangerous  injuries, 
death  being  liable  to  occur  from  penetration  of  the  cord 
by  fragments  of  bone.     Notwithstanding  the  grave  prog- 


FRACTURES  OF  THE   CERVICAL    VERTEBRA.       155 


nosis  attaching  to  fractui-cs  of  the  axis  and  atlas,  they  do 
not  necessarily  prove  fatal  in  all  cases.  Cases  of  rec<jveiy 
from  fracture  of  the  odontoid  process,  for  instance,  are 
on  record. 

Fi'actures  of  the  axis  and  of  all  the  other  cervical  ver- 
tebrae are  caused  by  indirect  violence.  They  are  usually 
the  result  of  forced  flexion  (compression-fractures),  the 
bodies  of  the  vertebrae  being  com- 
pressed in  their  vertebral  diameter. 
The  lesion  may  be  due  to  a  fall  on  the 
head  or  to  blows  received  on  the  latter 
from  falling  objects.  It  is  usually 
accompanied  by  concussion  of  the 
brain,  which  is  very  likely  to  divert 
attention  fit)m  the  spine  to  the  head. 
Sometimes  there  is  only  a  tem})orary 
condition  of  sh(jck,  and  cases  of  frac- 
ture of  the  axis  have  occurred  in  which 
the  injured  individual  has  proceeded 
on  his  way  after  recovering  from  the 
shock.  It  is  quite  possible,  under  such 
circumstances,  for  fracture  of  the  ver- 
tebrae to  be  overlooked  ;  and  if  the 
patient  actually  visits  a  physician  liim- 
self,  the  occurrence  of  the  fracture 
may  later  on  be  denied  and  its  existence 
declared  to  be  impossible. 

The  spinous  processes  most  subject 
to  fracture  are  those  of  the  second 
(which  is  long),  the  sixth,  and  the 
seventh  vertebrae.  The  injury  may  be  caused  by  direct 
violence  or  may  result  from  overextension,  the  spinous 
process  next  below  acting  as  a  fulcrum.  In  other  cases  it 
occurs  as  an  accompaniment  of  dislocations  due  to  over- 
flexion,  being  caused  In-  traction  on  the  part  of  the  liga- 
mentum  nuchae.  These  fractures  usually  involve  no 
danger  to  the  patient. 


Fig.  11. 


156  DISEASES  CAUSED  BY  ACCIDENTS. 

Fractures  of  the  luminse,  on  the  other  hand,  are  much 
more  serious  injuries,  being  very  liable  to  cause  lesions  of 
the  cord. 

The  prognosis  is  good,  as  a  rule,  in  respect  to  fractures 
of  the  transverse  processes  and  of  the  articukir  processes. 

Case  of  healed  fracture  of  the  spi)ioHS  process  of  the  seventh  cervical 
and  first  dorsal  verfebrse. 

A  carpenter,  thirty  years  of  age,  fell  from  a  height  of  twelve  feet 
on  June  29,  1891,  striking  on  the  neck.  In  addition  to  the  injury 
named  he  suffered  a  sprain  of  the  left  ankle.  When  I  examined  him, 
September  23,  1891,  I  found  the  head  held  as  in  the  accompanying 
illustration.  (Fig.  11.)  All  movement  of  the  head  was  very  difficult, 
and  the  spinous  processes  of  the  injured  vertebraj  were  swollen  and 
sensitive  to  pressure.  Tiie  central  nervous  sy.stem  was  intact.  Grad- 
ual improvement  resulted  from  treatment  by  massage  and  fioni  passive 
motion.  Insurance  allowance,  40%  for  the  first  si.x  months  ;  20%  for 
the  following  year.  After  this  time  the  patient  was  fully  capable  of 
self-support. 

Symptoms  of  Healed  Fractures  of  the  Cervical  Vertebrse. 

In  all  cases  of  healed  fractures  of  the  cervical  vertebrse 
we  can  observe  a  peculiar  and  rather  stiif  position  of  the 
liead.  When  it  is  inclined  forward,  we  can  assume  the 
lesion  to  have  been  a  fracture  or  dislocation-fracture  caused 
by  overflexion.  There  is  often  at  the  same  time  a  slight 
rotation  of  the  head  (caput  obstipum),  which  is  usually  to 
be  ascribed  to  a  unilateral  rotatory  dislocation  or  fracture. 
In  many  cases  the  neck  is  permanently  thickened  and 
swollen.  In  case  of  fracture  of  the  spinous  processes 
these  are  felt  to  be  thickened,  and  can  usually  be  easily 
seen.  \Yhen  there  is  a  rotation  of  the  head,  the  spinous 
processes  are  found  to  be  disjilaced.  Sometimes  the  cervi- 
cal region  of  the  spine  is  markedly  convex  posteriorly. 

Paralyses  affecting  the  cervical  or  brachial  plexus  may 
be  caused  by  hemorrhage  within  the  cord  or  by  pressure  of 
masses  of  callus  on  the  nerves  at  the  intervertebral  foramina. 

The  most  imj)ortant  of  the  functional  disturbances  are 
the  limitations  of  mobility.  A  workman  may  be  seriously 
inconvenienced  by  inability  to  raise  his  head.  Limitation 
of  lateral  movement  is  also  extremelv  annovino;. 


FRACTURES  OF  THE  CERVICAL    VERTEBRAE.       157 

Movement  of  the  head  t'requeiitly  gives  rise  to  cracking 
sounds,  usually  not  accompanied  l)y  pain,  l)nt  so  unpleas- 
ant that  the  individual  aii'ected  is  aj)t  to  avoid  moving  his 
head  as  much  as  possible. 

There  is  not  necessarily  a  loss  of  capacity  for  self-sup- 
port, unless  there  are  cerebral  symptoms  or  paralyses. 
If  the  latter  are  present,  the  incapacity  for  self-support 
always  reaches  a  high  degree. 

Case  of  healed  d islocaiioii-fracture  of  the  cervical  vertebrae,  compli- 
cated by  concussion  of  the  brain. 

A  carpenter,  thirty-four  years  of  age,  was  caught  under  a  falling 
building  on  February  3,  1897.  Lesion  :  severe  contusion  of  the  cervi- 
cal region  of  the  spine  and  of  the  left  arm.  He  was  in  the  hospital 
for  three  aud  a  half  weeks,  and  came  under  my  care  on  May  3,  1897. 

The  patient  was  a  large  man,  of  vigorous  build.  The  head  was 
somewhat  inclined  forward  and  to  the  left  side,  the  left  ear  being  on  a 
slightly  lower  level  than  the  right.  The  second  spinous  process  was 
slightly  displaced  to  the  left.  There  was  some  stiffness  of  the  neck, 
and  movement  of  the  head  was  greatly  restricted.  On  passive  motion 
there  was  slight  crepitation  in  the  spinous  processes  of  the  lower  part 
of  the  cervical  region.  The  riglit  pn])il  was  dilated  and  reacted 
slowl}'.  The  patient  complained  of  dizziness.  He  could  raise  his 
left  arm  only  to  an  angle  of  100  degrees,  and  could  not  close  his  left 
hand.  The  whole  left  arm  showed  signs  of  paretic  disturbances. 
The  leftr  patellar  reflex  was  exaggerated  ;  the  gait  was  rather  dragging. 
X-ray  photogra|)hs  showed  a  healed  dislocatiou-fracture  of  the  fifth 
cervical  vertebra,  with  slight  rotation  to  the  left,  confirming  the  diag- 
nosis of  injury  to  the  central  nervous  system. 

Treatment. — Massage  aud  passive  motion.  Improvement  very  slow 
and  slight.  The  patient  remained  somewhat  depressed.  Discharged 
January  20.  1898,  with  60%  insurance  allowance,  afterward  iucreased 
by  legal  process  to  7d%.     No  change  in  his  condition  up  to  date. 

Crt.se  of  healed  dislocation-fracture  of  the  fifth  cervical  vertebra. 

A  plasterer,  thirty-two  years  of  age,  fell  from  a  .scaffolding  six 
feet  high  on  November  29,  1898,  striking  the  back  of  his  head  on  a 
beam.  After  a  very  .sliort  period  of  unconsciousness  he  rose  to  his 
feet  of  his  own  accord  ;  spontaneous  extension  movements  of  the  right 
arm  lasting  for  several  minutes  are  said  to  have  occurred  immediately 
afterward.  The  head  was  inclined  forward  from  the  first.  He  walked 
home  and  then  to  the  doctor's  office,  where  the  fracture  was  diagnosed 
and  treatment  by  appropriate  iiosition  ordered.  On  the  following  day 
he  entered  a  surgical  clinic  for  treatment.  After  an  X-ray  photo- 
graph had  been  taken  the  dislocation  was  reduced.  1  examined  him 
on  February  3,  1899.  He  was  a  man  of  medium  height  and  of  vigor- 
ous build.  He  complained  of  pain  in  the  back  of  the  neck, 
radiating  toward  the  shoulders,  of  inability  to  move  his  head,  of  pain 


158  DISEASES  CAUSED  BY  ACCIDENTS. 

in  the  sternum  and  in  the  lumbar  region  after  sitting  for  any  length 
of  time,  and  of  numl)ne.ss  of  the  left  arm. 

The  following  points  were  especially  noticeable  when  the  patient 
was  viewed  froni  the  side  :  forward  inclination  of  the  head  ;  marked 
prominence  of  the  sternocleidomastoid  ;  prominence  of  the  spinous 
processes  of  the  tilth,  sixth,  and  seventh  cervical  vertelira?.  The  left 
ear  was  slightly  lower  than  the  right.  IMovemeut  of  the  head  was 
limited  and  painful.  The  patient  wore  a  stiff  bandage  around  the 
neck.     He  is  still  quite  incapable  of  self-support. 

Fractures  of  the  Dorsal  and  Lumbar  Vertebrae. 

Fractures  of  the  dorsal  vertebrse  call  for  special  discus- 
sion by  reason  of  the  connection  of  the  vertebrae  M'ith  the 
ribs.  If  the  transverse  processes  are  involved,  the  union 
with  the  ribs  is  loosened  or  destroyed,  and  after  recovery 
there  are  likely  to  be  mechanical  limitations  of  mobility, 
or  ])ain  due  to  neuralgia,  or  inflammation  arising  from 
pressure  on  the  intercostal  nerves.  Similar  symjitoms  are 
also  observed  when  the  ribs  are  fractured  near  their  ver- 
tebral articulations.  The  heads  of  the  ribs  are  frequently 
loosened  or  displaced  from  their  articidations  with  the 
intervertebral  discs  in  case  of  fracture  of  the  bodies  of  the 
vertebrae.  These  dislocations  are  very  likely  to  cause  pain 
on  every  motion  of  the  thorax.  The  pain  may  l)e  localized 
at  the  point  of  injury,  or  it  may  radiate  in  the  course  of 
the  intercostal  nerves  involved.  In  addition,  there  are 
disturbances  undouV)tedly  due  to  lesions  of  the  sym])athetic 
nerve,  which  passes  down  the  vertebral  coluinn  close  to  the 
costal  articulations,  and  to  lesions  of  its  small  ganglia,  one 
of  which  corresponds  to  each  rib,  and  into  which  the 
nerye-branches  i)ass  connecting  the  sympathetic  and  spinal 
systems.  The  symptoms  to  be  attributed  to  these  lesions 
are  disturbances  of  heart-action,  such  as  slow  or  intermit- 
tent pulse. 

When  the  eleventh  or  twelfth  dorsal  vertebra  is  involved, 
the  conditions  that  arise  from  the  injury  are  somewhat 
different,  since  these  vertebrae  are  connected  with  the  two 
floating  ribs. 

The  consequences  of  injuries  of  the  cord  at  the  various 


FRA  CTURES  OF  DORS  A  L  A  ND  L  U3IBAR  VERTEBRAE.     159 

levels  of  the  dorsal  region  have  already  received  sufficient 
mention. 

While  dislocations  or  dislocation-fractures  are  the  ride 
in  the  cervical  region,  pure  fractures  are  the  chief  form  of 
injury  affecting  the  dorsal  and  lumbar  vertebrae.  Of 
these,  the  lower  dorsal  and  up[)er  lumbar  vertebne  are 
most  frequently  involved,  and  by  most  observers  the 
twelfth  dorsal  and  first  lumbar  vertebrae  are  stated  to  be 
the  seat  of  injury  in  the  majority  of  cases.  My  own 
statistics  fully  agree  with  this  conclusion.  Wagner  and 
Stolper  noted  thirty-five  fractures  of  the  twelfth  dorsal 
vertebra  among  sixty-eight  cases  of  fracture  and  disloca- 
tion ;  and  nineteen  fractures  of  the  first  lumbar  vertebra 
amone:  thirtv-four  cases  of  involvement  of  the  lumliar 
region.     Gowers  gives  very  similar  figures. 

Fractures  of  the  bodies  of  the  dorsal  and  lumbar  ver- 
tebrae are  compression-fractures  in  the  great  majority  of 
cases,  being  caused  by  falls  on  the  feet,  buttocks,  head,  or 
neck,  or  by  blows  from  falling  oljjects  received  on  the 
shouldei's,  or  by  forced  overflexion  of  the  body  in  cases 
of  caving-in  of  walls,  etc.  Such  fractures  are  due  to  in- 
direct violence,  and  it  may  be  stated  that  fractures  of  the 
bodies  are  only  in  rare  instances  the  result  of  direct 
violence. 

As  a  result  of  the  accidents  just  enumerated  the  bodies 
of  the  vertebrae  are  compressed  in  their  vertical  axis.  If 
at  the  same  time  the  spine  is  overflexed,  it  is  the  ante- 
rior parts  of  the  bodies  that  are  chiefly  aflFected  by  the 
compression.  As  a  result  we  often  meet  with  indirect 
fractures  of  one  or  more  of  the  spinous  processes,  with 
lacerations  of  the  ligaments  connecting  them,  especially 
of  the  supraspinous  ligament.  Sometimes  the  sternum  is 
transversely  fractured  at  the  same  time.  It  has  not  yet 
been  determined  how  much  the  transverse  and  articular 
processes  of  the  vertebrae  are  involved  in  the  injury. 
Wagner  and  Stolper  have  found  on  auto[)sy  tliat  the 
articular    processes   and   capsules    were    uninjured    in    a 


160  DISEASES   CAUSED  BY  ACCIDENTS. 

luiinhtT  of  cases  of  serious  compression-fracture.  Never- 
theless, it  is  only  reasonable  to  suppose  that,  in  some  in- 
stances in  which  the  compression  is  more  marked  in  the 
posterior  than  in  the  anterior  segments  of  the  bodies,  the 
articuUu"  processes  may  also  sutler  fracture. 

The  spinous  processes  are  very  frequently  the  seat  of 
fracture ;  and  when  they  alone  sutler,  the  injury  is  due  to 
direct  violence,  usually  acting  at  a  tangent  and  involving 
several  spinous  processes  at  the  same  time.  The  indirect 
fractures  of  the  spinous  processes  accompanying  similar 
injuries  of  the  bodies  of  the  vertebrse  have  been  pre- 
viously mentioned. 

Fractures  of  the  lamina  of  the  dorsal  and  lumbar  ver- 
tel)nB  occur  so  seldom  that,  ac^cording  to  AAagner  and 
Stolper,  only  five  cases  are  on  record  so  far.  These  frac- 
tures necessarily  involve  great  danger  to  the  cord. 

C((.s(;  of  healed  compression- fracture  of  fhe  eleventh  and  twelfth  dorsal 
vertehrse,  complicated  by  lesion  of  the  cord.  Sequel,  Kumniel's  curva- 
ture of  the  spiue. 

A  workman,  twenty-eight  years  of  age,  fell  from  a  heiglit  of 
one  story  June  28,  1898.  He  was  treated  iu  the  hospital  by  rest  iu 
bed  on  rubber  cushions.  There  were  anesthesia  of  both  lower  ex- 
tremities for  four  days  ;  retention  of  urine,  necessitating  catheteriza- 
tion lor  three  days  ;  absolute  constipation  for  from  ten  to  twelve  days. 
I  examined  liiiii  September  3,  1K9H.  when  he  had  been  out  of  the 
hosjiital  for  eight  weeks.  He  stated  that  he  felt  strong  enough  to 
work,  and  wished  to  do  so.  He  was  a  man  of  medium  size  and  vigor- 
ous Imild,  of  pale  complexion  and  sickly  appearance.  The  spinous 
processes  of  the  eleventh  and  twelfth  dorsal  vertehrse  were  somewhat 
thickened  and  appeared  a  little  sejiiirated  ;  they  were  not  ])ainfnl  on 
pressure.  The  spine  showetl  a  slight  posterior  curvature  in  this  region. 
The  patient  could  stoop  forward  easily,  and  could  raise  liimself 
])romptly  and  quickly  ;  lateral  flexion  and  retrotiexion  were  rather 
difficult.     Insurance  allowance,  25%. 

The  ])atient  now  begun  to  work  again.  After  twenty-seven  days  he 
returned  for  a  new  examination,  saying  that  he  had  pain  in  the  sjjine 
and  was  unable  to  work.  He  admitted  having  worked  continuously  for 
ten  hours  and  having  carried  heavy  weights.  At  this  time  the  sjiinoiis 
processes  of  the  elerenth  and  twelfth  dorsal  vertehrx  were  somewhat  dis- 
placed und  ihe  kyphosis  was  more  marked.  On  December  31,  1898, 
I  made  another  examination,  and  found  a  much  increased  kyphosis, 
as  illustiated  in  the  a.cc()m])anying  drawing.  (Fig.  12.  lMiotograi)hed 
from  outline  made  with  lead  wire.)  The  ])atient  had  evidently  begun 
to  woik  again  too  soon,  es[iecially  in  regard  to  carrying  loads.     The 


FRA CrURES  OF  DORSAL  AND  L UMBAR  VERTEBRA.     101 


Fig.  13. 


Fig.   12.  Fig.  14. 

11 


162  DISEASES  CAUSED  BY  ACCIDENTS. 

cancellous  portion  of  the  fractured  vertebra3  was  undoubtedly  still  too 
soft  to  give  the  proper  support.  On  anteflexion  the  two  spinous  pi'o- 
cesses  in  question  stood  out,  as  sliowu  in  the  drawing.  (Fig.  13.)  At 
this  time  it  was  difficult  for  the  ])atient  to  recover  the  upright  position. 
On  retroflexion  (Fig.  14)  the  cervical  and  dorsal  regions ofthespiue  stood 
to  each  other  at  an  augle  of  nearly  ninety  degrees  ;  the  dorsal  region 
remained  kyphotic,  while  the  lumbar  region  could  be  flexed  in  lordosis. 
On  lateral  flexion  the  dorsal  region  invarialily  moved  in  the  opposite 
direction  ;  on  flexion  to  the  left  (Fig.  15),  therefore,  the  dorsal  region 
l)ecame  convex  on  the  left  side,  while  the  cervical  and  luni))ar  regions 
became  concave  on  the  left  side  ;  on  flexion  to  tlie  right,  the  convexity 
appeared  on  the  right  side  of  the  lumbar  region.  (Fig.  16.)  The 
patient  had  lost  four  centimeters  in  height  since  his  accident.  His 
insurance  was  raised  to  50^ 


Symptoms  of  Healed  Fractures  of  the  Spine. 

As  a  result  of  isolated  fractures  of  the  s])inous  processes, 
usually  due  to  direct  violence  acting  at  a  tangent,  we  find 
the  affected  processes  thickened,  prominent,  and  either  ap- 
proximated or  separated  more  widely  than  in  the  normal 
state.  The  mobility  of  the  spine  is  limited  for  a  consider- 
able period  ;  in  especially  unfavorable  cases  the  limitation 
may  be  permanent.  Lesions  of  the  spinal  cord  may  be 
caused  by  direct  penetration  of  the  latter  by  the  fractured 
process. 

The  symptoms  consequent  uj)on  fracture  of  the  bodies 
are  more  characteristic.  A  peculiar  stiff  manner  of  hold- 
ing the  body  is  often  apparent  at  a  glance,  while  on  exam- 
ination of  the  spine  we  usually  find  a  spot  at  which  one  or 
more  of  the  spinous  processes  seem  thickened.  The  frac- 
ture of  the  body  may  correspond  with  the  spinous  process 
that  was  simultaneously  involved,  or  it  may  l)e  situated  lower 
down.  It  is  unusual  for  it  to  be  at  a  higher  level.  The 
callous  thickening  of  the  fractured  spinous  processes  may 
be  so  marked  as  to  form  a  decided  angular  or  rounded 
gibbosity.  In  other  cases  the  spinous  processes  are  only 
very  slightly  thickened.  The  gibbosity  is,  as  a  rule, 
largest  in  the  cases  of  fracture  due  to  overflexion  accojn- 
panied.  by  compression  of  the  anterior  segments  of  the 
bodies  of  the  vertebrae.     It  mav  increase  in  size  as  a  result 


HEALED  FRACTURES  OF  THE  SPINE.  163 

of  walking  too  soon  after  the  accident  (Kiimniel's  disease). 
If  the  gibbosity  is  marked,  the  wliole  back  at  that  level  is 
shaped  to  a  point  in  the  direction  of  the  spine  ;  in  the  lum- 
bar region  especially  the  normal  depressions  and  curves 
seen  on  l)oth  sides  of  the  long  extensor  muscles  of  the 
back  will  be  found  to  have  disappeared.  As  a  result  of 
these  changes  the  whole  body  is  sometimes  held  slightly 
inclined  forward.  The  opposite  condition  obtains  when 
the  posterior  segments  of  the  bodies  of  the  vertebrte  are 
aflt'ected  by  the  compression,  the  curvature  of  the  spine  in 
these  cases  being  lordotic,  and  leading  to  a  noticeable  pecu- 
liarity of  posture  and  gait.  The  latter  may  be  mincing  or 
dragging.  The  spinous  processes  may  be  widely  separated 
or  they  may  be  closely  pressed  together.  In  all  cases  of 
compression-fracture  the  vertebral  column  is  found  to  be. 
shortened.  In  men  who  have  been  accurately  measured  for 
military  service  previously  to  the  accident  the  degree  of 
shortening  can  be  determined  with  exactness.  The  thorax 
frequently  appears  barrel-shaped.  In  the  region  of  the 
fracture  the  spine  shows  a  certain  stiffness,  which  can  best 
be  demonstrated  by  pressure,  with  the  patient  lying  on  his 
stomach,  in  comparison  with  a  normal  individual.  The 
muscles  of  the  back  often  remain  atrophied  for  a  consider- 
able period. 

Case  of  fracture  of  the  spinous  processes  of  the  tenth  to  the  twelfth  dorsal 
vertebras.     Sequel,  perfect  recovery. 

A  workman,  forty-five  years  of  age,  on  July  27,  1896,  fell  from  a 
scaffolding  one  story  high,  striking  on  his  back.  He  was  taken 
to  the  hospital,  where  he  was  kept  in  bed  on  air-cushions  and 
treated  )>y  inunctions.  I  examined  him  Septeml)er  10,  1896.  He 
was  of  medium  size  and  of  lieaithy  appearance.  He  held  his  body 
somewhat  inclined  forward.  The  tcntli  to  twelfth  spinous  processes 
were  thickened  and  prominent.  His  gait  was  slow,  })ut  not  irregular  ; 
all  motion  of  the  spine  was  difficult  and  painful.  After  deep  flexion 
he  raised  himself  by  climbing  up  his  thighs  with  his  hands.  The 
patellar  reflexes  were  exaggerated  on  both  sides.  He  was  treated  in 
my  hospital  for  four  months,  and  was  then  discharged  with  20% 
insurance  allowance.  At  that  time  he  still  complained  of  pain  in  the 
spine,  but  could  stooj)  easily  and  quickly.  Since  January,  1898,  he 
has  been  in  perfect  health. 

Case  of  healed  fracture  of  the  ninth  and  tenth  dorsal  vertebras,  covipli- 


164 


DISEASES  CAUSED  BY  ACCIDENTS. 


catcd  hy  fracture  of  the  rihs.    Sequel  :  recovery,  with  serious  iunctioual 
disturlninces. 

(Compare  Plate  11.)  A  mason,  thirty-five  years  of  age,  on  October 
5,  1897,  fell  from  a  wall  about  twenty  feet  high,  striking,  so  it  is 
said,  on  the  himl»ar  region.  This  point  could  not  be  definitely  ascer- 
tained. The  patient  remained  in  bed  ibr  sixteen  days,  and  after  that 
arose  at  intervals.     Urination  and  defecation  were  disturbed. 


I  examined  him  December  28,  1895.  He  was  of  medium  size,  well 
nourished,  but  had  a  look  of  ill  health.  He  held  his  body  inclined 
backward  and  walked  with  a  mincing  gait.  From  the  front  his  neck 
appeared  short  and  as  if  sunk  into  the  thorax.  Tlie  abdomen  was 
boat-shaped  and  the  thorax  appeared  somewhat  asymmetric.  There 
was  relatively  marked  lordosis  of  the  lumbar  region,  while  the  upper 
dorsal  region  was  somewhat  abnormally  convex  posteriorly.  Tlie 
spinous  processes  of  the  tenth  and  eleventh  dorsal  vertebrse  were  con- 
siderably thickened.     At  the  time  of  his  military  service  the  patient 


A  TEXT-BOOK  OF  OBSTETRICS. 

By  Barton  Cooke  Hirst,  M.D.,  Pro- 
fessor of  Obstetrics 
in  the  University 
of      Pennsylvania. 


HIRST'S 
OBSTETRICS 


Handsome  octavo  volume  of  846 
pages*  6t8  illustrations  and  7  colored 
plates.  Cloth,  $5.00  net;  Half  Mo- 
rocco, $6.00  net.  J-  J-  J-  J>  J- 
SECOND  EDITION. 

This  work  is  intended  as  an  ideal  text-book  for 
the  student  no  less  than  an  advanced  treatise  for 
the  obstetrician  and  for  general  practitioners.  It 
represents  the  very  latest  teaching  in  the  practice 
of  obstetrics  by  a  man  of  extended  experience  and 
recognized  authority.  The  book  emphasizes 
especially,  as  a  -work  on  obstetrics  should,  the 


"The  illustrations  are  numerous  and  are  works  of 
art,  many  of  them  appearing  for  the  first  time.  The 
arrangement  of  the  subject-matter,  the  foot-notes,  and 
index  are  beyond  criticism.  As  a  true  model  of  what 
a  moderii  te.\t-book  on  obstetrics  should  be,  we  feel 
justified  in  affirming  that  Dr.  Hirst's  book  is  without 
a  rival."— AVjy  Yok  Medical  Record. 


practical  side  of  the  subject,  and  to  this  end  pre- 
sents an  unusually  large  collection  of  illustra- 
tions. Most  of  these  are  new,  and  the  collec- 
tion will  form  a  complete  atlas  of  obstetrical 
practice.  This  work  records  the  wide  experi- 
ence of  the  author,  which  fact,  combined  with 
the  brilliant  presentation  of  the  subject,  renders 
it  one  of  the  most  notable  bocks  on  obstetrics. 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philac^elphia. 


LECTURES  ON  THE  PRINCI- 
PLES OF  SURGERY.  By  Charles 
B.  Nancrede,  M.D.,  LL.D.,  Professor 
of  Surgfery  and 
of  Clinical  Sur- 
gery, University 
of         Michigan, 


NANCREDE'S 
PRINCIPLES  OF 
SURGERY. 


Ann  Arbor;  Emeritus  Professor  of 
General  and  Orthopedic  Surgery,  Phi- 
ladelphia Polyclinic  Octavo  volume 
of  about  350  pages,  handsomely  illus- 
trated with  original  drawings  and  pho- 
tographs.   Cloth,  $2.50  net.   ^   J-   ^ 

JUST  ISSUED. 


Although  many  excellent  works  have  been 
written  treating  of  the  Principles  of  Surgery, 
the  attempt  to  render  them  too  comprehensive 
has  marred  their  usefulness  for  the  undergrad- 
uate. The  present  book  is  based  on  the  lectures 
delivered  by  Dr.  Nancrede  to  his  undergraduate 
classes,  and  is  intended  as  a  text-book  for  stu- 
dents and  a  practical  help  for  teachers.  By  the 
careful  elimination  of  unnecessary  details  of 
pathology,  bacteriology,  etc.,  which  are  amply 
provided  for  in  other  courses  of  study,  space  is 
gained  for  a  more  extended  consideration  of  the 
Principles  of  Surgery  in  themselves,  and  of  the 
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For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


HEALED  FRACTURES  OF  THE  SPINE.  165 

had  measured  1.61  meters.  His  present  height  is  only  1.57  meters. 
There  were  no  paralyses  or  disturl)ances  of  sensil)iiity.  All  the 
reflexes  were  exaggerated,  and  the  pulse  was  increased  in  frequency. 
Motion  of  the  spine  Avas  difficult  and  painful  ;  the  patient  walked 
mincingly  and  with  the  help  of  a  cane.  Insurance  allowance  100^  ; 
no  improvement  up  to  date. 

Case  of  fracture  of  Vie  twelfth  dorsal  and  first  lumbar  vertebras; 
recovery. 

A  chimney-sweep,  thirty-eight  years  of  age,  on  December  20, 
1888,  fell  from  a  height  of  al)Out  200  feet,  fracturing  his  spine  and 
right  ankle.  He  was  treated  in  the  hospital.  I  examined  him  March 
28,  1889,  and  noticed  the  forward  inclination  of  the  body  shown  in 
the  accompanying  illustration.  (Fig.  17.)  Tlie  lower  dorsal  and 
lumbar  regions  of  the  spine  were  slightly  thickened.  He  was  unalile 
to  straighten  his  body.  He  suffered  constantly  from  diarrhea,  which 
yielded  only  to  large  doses  of  laudanum.  Up  to  the  end  of  1890  he 
was  frequently  treated  in  the  hospital,  and  at  that  time  was  discharged 
with  25  fo  insurance  allowance.  He  afterward  resumed  his  trade,  but 
on  July  2,  1897,  he  again  fell  from  a  height,  and  died  on  the  following 
day. 

The  spine  is  generally  fixed  on  movement  of  the  body, 
giving  the  patient  a  stiff  appearance.  Stooping  is  often 
performed  by  bending  the  knees,  while  the  spine  is  held 
fixed  and  rather  straight,  the  patient  straightening  himself 
up  by  placing  his  hands  on  the  thighs.  Even  if  the 
spine  is  flexed  on  stooping,  the  movement  is  usually  very 
limited.  The  patient,  as  a  rule,  complains  of  weakness, 
of  a  feeling  of  insecurity,  and  of  pain  (ju  movement  of 
the  spine  in  any  direction  ;  the  pain  can  often  be  local- 
ized by  pressure  on  the  spinous  processes  or  by  percussion 
of  the  spine.  The  pain  may  disappear  in  the  course  of 
time,  or  it  may  increase  as  the  compressed  intervertebral 
disc  becomes  absorl^ed.  On  lateral  flexion  of  the  body 
the  spine  is  frequently  found  to  be  curved  in  the  opposite 
direction  at  the  point  of  injury  ;  in  rare  instances,  on  the 
other  hand,  there  is  an  abnormal  degree  of  lateral 
mobility.  The  jiatients  are  often  unable  to  walk  without 
a  cane.  If  the  injury  was  complicated  by  lesions  of  the 
cord  or  by  hemorrhages  into  its  substance,  the  gait  of  the 
patient  becomes  spastic  or  ataxic.  Paralyses  of  bladder 
and  rectum  are  not  infre(|uently  met  with,  accompanied 
by  albuminuria,  etc.,  causing,  in  these  severe  cases,  incon- 


166  DISEASES   CAUSED  BY  ACCIDENTS. 

tinenee  of  urine  and  feces  or  the  opposite  condition  of 
retention.  The  reflexes  may  be  diminished  or  lost,  or 
they  may  be  exaggerated.  In  case  of  unilateral  lesion 
of  the  cord  we  find  the  patellar  reflex  diminished  or  lost 
on  one  side  and  exaggerated  on  the  other.  On  the  side 
on  which  it  is  lost  the  muscles  are  usually  atrophied, 
while  the  skin  is  cool  and  insensitive  to  pain,  deep  pricks 
not  being  felt.  The  electric  irritability  may  be  only 
diminished,  or  the  reaction  of  degeneration  may  be 
present.  The  electric  irritability  may,  however,  be 
restored  for  some  time  before  the  disturbances  of  sensi- 
bility pass  ofl'. 

The  prognosis  of  fractures  of  the  vertebrae — more  ]>ar- 
ticularly  of  fractures  of  the  body — is  always  grave.  The 
j)rognosis  as  to  life  is  very  bad  in  serious  cases  complicated 
by  lesion -of  the  cord,  most  of  the  patients  dying  in  the 
course  of  two  years  in  consequence  of  complications.  Less 
severe  cases,  not  terminating  fatally,  are  almost  always 
followed  by  disturbances  of  function,  as  described  under 
Symptomatology. 

We  do  not  need  to  give  much  attention  to  fractures  of 
the  laminte,  since  they  very  seldom  occur  alone.  They 
are  always  very  serious,  because  of  probable  injury  of  the 
cord ;  if  the  cord,  however,  escapes,  fractures  of  the 
laminie  are  very  difficult  to  diagnose. 

Fractures  of  the  transverse  and  articular  processes  have 
been  referred  to  under  Anatomicophysiohjgic  Considera- 
tions. 

Case  of  fnichirr  of  the  lumhar  vrvtehrve  with  fraetnre  of  several  S2)i)ious 
processes,  coinptieated  hi/  lesion  of  the  cord.  Secjuel :  recovery  with  augii- 
lar  curvature  of  the  spine  ;  full  recovery  of  fuuctioiuU  jjowcr. 

A  painter's  apprentice,  seventeen  years  of  age,  in  1869  fell  from  a 
scaffdhling  from  twenty-five  to  thirty  feet  high,  striking  on  his  buttocks 
on  a  flight  of  stone  steps.  He  was  iu  the  hospital  for  twenty-two 
vreeks,  lying  on  a  water  bed  for  eighteen  weeks.  There  were  par- 
alysis of  the  lower  extremities  and  disturbances  of  sensibility  in  the 
.same  ;  also  paralysis  of  ))ladder  aud  rectum.  Three  weeks  after  in- 
jury a  bed-sore  developed  and  persisted  for  four  weeks.  Fouiteeu 
weeks  after  injury  the  patieut  complained  of  a  pricking  sensation  iu 


MEALED  FRACTURES  OF  THE  SPINE.  167 


Fig.  19. 


Fig.  18. 


Fig.  20. 


Fig.  21. 


168  DISEASES   CAUSED  BY  ACCIDENTS. 

the  lower  extremities.  The  patient  began  to  walk  on  crutches  nine- 
teen weeks  after  the  injury.  Nine  months  after  the  injury  he  resumed 
light  work,  and  was  able  to  do  his  full  amount  of  work  in  two  years. 

The  spine  is  markedly  kyj)h()tic  in  the  lumbar  region  (Fig.  18),  and 
the  thorax  appears  pointed  posteriorly.  On  anteflexion  (Figs.  19  and 
20)  the  spinous  processes,  which  are  thickened  and  further  apart  than 
normal,  become  more  prominent.  The  outline  of  the  spine  on  flexion 
is  shown  in  the  accompanying  drawing.  (Fig.  20.)  On  trying  to  bend 
backward  (Fig.  21)  the  dorsolumbar  region  retains  its  kyphosis.  On 
lateral  flexion  the  kyphotic  part  of  the  .spine  is  invariably  curved  in 
the  opposite  direction.  Figure  22  shows  the  outline  on  flexion  to  the 
right  ;  and  figure  23  the  outline  on  flexion  to  the  left. 

The  patient  has  been  perfectly  able  to  work  and  has  never  suffered 
from  any  further  symptoms  of  his  accident  twenty-nine  years  ago. 

In  respect  to  tlie  after-treatment  of  spinal  fractures,  a 
long  jieriod  of  rest  in  bed  is  to  be  recommended,  espe- 
cially in  consideration  of  tlie  soft  cancellous  substance  of 
the  bodies  of  the  vertebrte.  If  the  patient  is  allowed  to 
walk  too  soon,  the  weight  of  the  body  is  apt  to  cause  the 
formation  of  an  angular  spinal  curvature,  as  described  by 
Kiimmel.  As  an  additional  precaution  a  supporting  cor- 
set .should  be  worn  when  the  patient  begins  to  walk  about. 
Removable  plaster  supports  are  now  made  that  do  not  in- 
terfere with  treatment  by  massage  and  electricity.  The 
other  symptoms — limitation  of  spinal  mobility,  with  diffi- 
culty of  stooping — may  l>e  helped  by  massage  and  elec- 
tricity as  well  as  by  medicomechanical  exercises  as  soon 
as  it  is  proper  to  emj^loy  tlie  latter.  The  paralyses  are 
best  treated  by  galvanism,  alternating  with  faradism.  In 
some  cases  static  electricity  will  be  found  very  useful, 
especially  if  it  is  difficult  for  the  patients  to  undress 
them.selves,  when  the  skin  is  sensitive  to  the  air  or  to  wet 
electrodes,  or  when  they  are  especially  susceptible  to  sug- 
gestive treatment.  In  other  respects  treatment  is  purely 
symptomatic. 

In  many  cases  the  course  of  treatment  must  cover  a 
very  long  period.  In  case  of  serious  compression-frac- 
tures one  year  of  treatment  is  to  })e  anticipated,  although 
recovery  may  take  place  sooner.  The  patient,  however, 
may   be   able   to   resume  work   in  a  comparatively  short 


HEALED  FRACTURES  OF  THE  SPINE.  169 

time,  even  in  severe  cases.  We  must  bear  in  mind  that 
in  cases  of  compression-fracture  there  is  always  an  exten- 
sive growth  of  calhis  and  at  the  same  time  considerable 
absorption  of  bone  tissue,  and  that,  in  addition,  the  inter- 
vertebral discs  that  were  injured  at  the  time  of  fracture 
usually  undergo  com})lete  atrophy.  It  may  happen,  for 
these  reasons,  that  an  angular  cairvature  is  developed  some 
time  after  the  accident :  in  many  cases,  after  the  lapse  of 
some  years. 

Fracture  of  a  vertebra  may  give  rise  to  so  few  symp- 
toms that  it  is  overlooked  in  the  presence  of  other  more 
striking  injuries.  Wagner  and  Stolper  describe  a  case  in 
which  the  spinal  fracture  accompanied  fracture  of  the 
base  of  the  skull,  concussion  of  the  brain,  and  fracture 
of  the  thigh.  It  was  not  discovered  until  three  days 
after  the  accident,  Avhen  the  patient  complained  of  pain 
in  his  back.  I  have  known  of  cases  of  spinal  fracture 
that  occurred  in  conjunction  with  other  injuries  and  that 
were  overlooked,  in  spite  of  a  long  stay  in  the  hospital, 
for  the  reason  that  the  cord  was  uninjured  and  the  patient 
made  no  complaint.  Such  fractures  are  especially  likely 
to  be  undiscovered  if,  after  the  accident,  the  patient  is 
able  to  walk  to  his  home  (^r  to  the  doctor's  office.  Refer- 
ence to  cases  of  this  description  can  be  found  in  the  works 
of  Wagner  and  Stolper. 

Case  of  fracture  of  the  lumbar  vei-iebrae,  complicated  hy  a  nnilateial 
lesion  of  the  cord.  Sequel  :  recovery,  with  paralysis  of  the  right  lower 
extremity,  myelitis,  ej'stitis,  and  nephritis. 

A  workman,  thirty-three  years  of  age,  as  he  was  engaged  iu 
pulling  down  a  wall,  on  August  6,  1895,  was  hit  on  the  hack  hy  a 
numher  of  falling  stones,  heing  iu  a  stooping  position  at  the  tiine. 
He  was  knocked  down  and  could  not  arise  again.  He  was  treated  in 
the  hospital  until  March  22,  1H96.  He  sutfered  from  paralysis  of  the 
bladder  and  rectum,  bloody  urine,  and  retention,  alternating  with  in- 
continence of  urine.  I  examined  him  on  April  9th.  He  was  a  rather 
large  man,  pale  and  sickly  in  appearance  ;  he  walked  with  difficulty, 
leaning  on  two  canes.  There  was  a  very  slight  kyphosis  of  the  lum- 
bar region.  Botli  legs  showed  atrophy,  the  right  lieing  much  more 
affected.  On  walking,  the  right  leg  was  swung  foiward  from  the  hip, 
the  patient  being  uual)le  to  lift  it.  The  muscles  of  the  left  buttock  ap- 
peared very  tlabby  ;  a  sup2)urating  bed-.sore  still  persisted  iu  the  neigh- 


170  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  9. 

Case  of  Fracture  of  a  Lumbar  Vertebra  Following  a  Slight 
Injury. — Sequel,  tu})erculosis  of  the  lumbar  vertebite.  Kyphosis 
marked.  Death  occurred  seven  years  later  froui  tuberculosis  of  the 
brain. 

A  mason,  thirty-five  years  of  age,  on  attempting  to  lift  a  box  of 
lime  felt  something  "crack"  in  his  back,  and  had  to  stop  work  on 
account  of  pain.  Three  months  later  I  examined  him  and  found 
the  condition  here  illustrated.  He  walked  with  difficulty.  No 
paralyses. 

One  year  after  injury  :  paralysis  of  extremities  and  beginning  dis- 
turbances of  speech. 


borhood  of  the  anus.  The  ribs  felt  thickened  on  the  right  side  of  the 
back  under  the  scapula.  There  were  no  cardiac  murmurs  ;  pulse,  100. 
The  patellar  reflex  was  abolished  on  the  right  side,  diminished  on  the 
left.  The  temperature  was  raised.  The  urine  contained  considerable 
albumin  ;  there  was  a  purulent  cystitis.  He  entered  the  hospital.  I 
again  examined  the  patient  SeptemT)er  7,  1899  ;  except  in  respect  to 
the  cystitis,  which  was  cured,  there  was  no  change  in  his  condition. 
Insurance  allowance,  100%. 

Case  of  healed  fracture  of  the  lumhar  vertebral,  complicated  by  lesion  of 
the  cord.     Death  occurred  from  diabetes  mellitus  after  five  years. 

A  carpenter,  twenty-nine  years  of  age,  fell  from  a  scafltblding 
September  17,  1888.  He  was  treated  in  the  hospital  up  to  Decem- 
ber 20,  1888.  He  was  a  man  of  moderate  height.  At  the  level  of  tlie 
first  and  second  lumbar  vertebrae  there  was  a  slight  but  distinct 
angular  (;urvature.  Other  symptoms  were  sensitiveness  to  pressure, 
difficulty  of  motion,  inability  to  stoop,  and  paresthesia  of  the  lower 
extremities  ;  the  ])atellar  reflex  was  exaggerated  on  the  right  side  ; 
there  was  incontinence  of  urine  and  of  feces.  The  patient  gradually 
grew  worse,  and  died  October  13,  1893,  of  diabetes. 

In  tlie  majority  of  cases  of  healed  fractures  there  is  a 
considerable  degree  of  incapacity  for  self-support ;  in  my 
own  cases  33 J  to  50  ^y  insurance  was  usually  allowed. 
Fully  one-third  of  all  cases  received  100^.  Nevertheless, 
we  sometimes  meet  with  cases  of  severe  injury  in  which 
the  victim,  although  outwardly  changed  in  consequence, 
is  able  to  resume  work  in  a  comparatively  short  time. 

Traumatic  Diseases  of  the  Spine  and  the  Spinal  Cord. 

Tuberculosis  (Caries)  of  the  Spine. — The  spine  in 
both  children  and  adults  is  a  favorite  seat  for  the  develop- 


Tab.     It. 


/ 


K^^^^ 


lAth.  Anst  E  Reicfihold,  Uunrhen. 


TUMORS  OF  THE  SPINE.  171 

ment  of  tuberculosis,  the  cancellous  tissue  of  the  bodies 
of  the  vertebrae  being  especially  subject  to  attack. 

We  are  not  concerned  here  with  frank  cases  of  spinal 
tuberculosis,  but  rather  with  the  latent  form  of  the  dis- 
ease as  it  exists  in  apparently^  healthy  individuals,  who 
are  able  to  do  their  regular  work  until  some  accident 
occurs  as  a  result  of  which  the  latent  process  is  stirred  to 
activitv,  permanently  incapacitating  the  aifected  person 
for  self-support.  The  traumatism  may  take  the  form  of 
a  contusion,  a  sprain,  or  a  dislocation,  or  it  may  be  so 
slight  as  scarcely  to  be  considered  an  injury  at  all.  The 
traumatism  frequently  results  in  the  fracture  of  a  verte- 
bra, leading  to  an  inflammation  of  the  cancellous  tissue 
and  the  fibrocartilaginous  discs,  which  subsequently  be- 
come suppurative  ;  or  the  process  may  be  partly  reversed, 
inflammation,  suppuration,  and  fracture  being  the  order 
of  sequence.  The  final  result  is  the  development  of  an 
angular  curvature  of  the  spine,  which  is  characteristic  of 
the  disease  under  consideration.  The  two  cases  illustmted 
in  this  section  (Figs.  7  and  8  and  Plate  9)  show  this  de- 
formity very  plainly. 

Tuberculous  vertebrte  are  exceedingly  fragile,  a  condi- 
tion that  must  necessarily  affect  the  spinal  meninges,  the 
nerve-roots,  and,  lastly,  the  spinal  cord  itself.  Persons 
aifected  with  spinal  tuberculosis  that  has  developed  in 
consequence  of  traumatism  are  regarded  as  entitled  to 
insurance. 

Infectious  inflammatory  processes  of  other  kinds,  of 
which  traumatism  may  act  as  the  exciting  cause, — osteo- 
myelitis and  actinomycosis,  for  example, — may  be  con- 
sidered to  belong  to  this  group  of  spinal  diseases,  of  which 
tuberculosis  is  the  most  prominent  member. 

The  Influence  of  Traumatism  on  the  Development 
of  Tumors  of  the  Spine. — Sdix-oiaata  and  carclnoinatd 
may  develop  secondarily  in  the  spine  as  a  result  of  metas- 
tasis from  a  ])rimary  growth  in  another  part  of  the  body, 
and  of  this   secondary   development   traumatism   may   be 


172  DISEASES  CAUSED  BY  ACCIDENTS. 

the  exciting  cause.  In  some  cases  primary  sarcomata, 
carcinomata,  and  myomata  are  said  to  have  developed  in 
consequence  of  traumatism. 

The  tumor  involves  the  vertebrae,  their  processes,  the 
nerve-roots,  and,  finally,  the  cord  and  its  meninges.  The 
bone  becomes  exceedingly  fragile,  and  slight  injuries  are 
likely  to  lead  to  fractures,  causing  lesions  of  the  cord  and, 
consequently,  paralyses.  In  other  cases  the  fragments 
become  displaced  gradually,  compressing  the  cord  slowly 
but  surely. 

The  relation  of  the  traumatism  to  the  tumor-growth  is 
clear  if  symptoms  begin  to  appear  at  once.  In  the  early 
stages  sensitiveness  to  pressure  and  pain  on  movement  are 
the  only  signs  of  the  troul)le  ;  later  on,  localized  inflam- 
mation and  the  growth  of  a  tumor  can  be  determined, 
followed  in  turn  by  spinal  curvature  and  paralyses,  and 
finally  by  cachexia. 

Traumatic  Diseases  of  the  Spinal  Meninges. 

The  secondary  affections  of  the  spinal  meninges  that 
concern  us  here  have  been  referred  to  in  the  beginning  of 
this  section.  Two  forms  of  chronic  inflammation  remain 
to  be  discussed  : 

1.  Hypertrophic  cervical  pachymeningitis. 

2.  Chronic  syphilitic  meningomyelitis. 

1.  The  lesion  consists  of  a  layer-like  gi'owth  of  fibrous 
tissue  in  the  dura  mater,  by  which  it  is  greatly  thickened. 
Adhesions  are  formed  with  the  periosteum  on  one  hand 
and  with  the  cord  and  nerve-roots  on  the  other;  the  lower 
part  of  the  cervical  cord  gradually  becomes  conq)ressed. 
As  a  result  of  this  compression  we  have  the  following 
characteristic  sym})toms  :  Fain  in  the  neck  and  between  the 
shoulders  and  in  the  back  of  the  head  ;  rigidity  of  the 
neck  ;  sensitiveness  to  pressure  over  the  cervical  vertebrae  ; 
neuritis  affecting  the  ulnar  and  median  nerves  ;  paresthe- 
sias :  degenerative  j)aralyses  of  the  small  muscles  of  the 
hand  and   of  the  flexors  of  the   fingers  ;  contractures  and 


COMPRESSION  MYELITIS.  173 

overextension  of  the  wrists,  cine  to  the  unbalanced  action 
of  tlie  extensors. 

The  affection  may  follow  traumatism  or  other  causes, 
such  as  strains,  exposure  to  cold,  syphilis,  and  chronic 
alcoholism. 

2.  Chronic  syphilitic  meningomyelitis  is,  as  its  name 
indicates,  a  specific  syphilitic  disease  of  the  cord  aud  its 
meninges,  and,  therefore,  a  descriptiou  is  not  in  place  here. 
Its  development,  however,  is  said  to  be  called  forth  by 
exposure  to  cold  and  by  traumatism. 

Compression  Myelitis. 

By  the  term  compression  myelitis  we  understand  an  in- 
flammation of  the  spinal  cord  caused  by  pressure  from  the 
bones  displaced  in  consequence  of  dislocation  or  fracture 
of  the  vertebrae.  The  inflannnation,  which  is  chronic  in 
nature,  may  also  be  caused  by  hemorrhage,  and  is  fre- 
quently observed  in  cases  of  carcinoma  and  caries.  The 
symptoms  are  as  follows  :  neuralgic  pains  in  the  spine, 
girdle  sensation,  pains  radiating  toward  the  extremities. 
In  addition,  there  are  special  symptoms,  varying  with  the 
level  at  which  the  lesion  occurs.  The  dorsal  region  is 
most  frequently  involved.  Lesions  here  are  followed  by 
a  spastic  paraplegia  of  the  lower  extremities,  disturbances 
of  sensation,  bladder  disorders,  etc.  If  only  one  side  of 
the  cord  is  affected,  we  have  the  symptoms  described  by 
Brown-Sequard. 

The  prognosis  is  grave,  death  usually  occurring  in  the 
course  of  one  or  two  years,  from  cystitis,  nephritis,  bed- 
sores, or  some  other  complication.  The  inflammation 
may  spread  in  a  transverse  diameter,  giving  rise  to  a 
myelitis  transversa,  or  it  attacks  different  places  in  the 
cord  and  becomes  a  myelitis  disseminata.  The  symptoms 
correspond  to  those  described  in  the  beginning  of  this 
section  in  regard  to  the  pathology  of  the  spinal  cord. 


174  DISEASES  CAUSED  BY  ACCIDENTS. 


Secondary  Degeneration. 

When,  in  consequence  of  tnunnati.sm,  nerve-fibers  are 
severed  from  their  tropliic  centers,  they  undergo  degenera- 
tion, whicli  may  take  a  descending  or  an  ascending  course 
according  to  the  position  of  the  centers,  whether  central  or 
peripheral.  In  the  case  cited  by  Wagner  and  Stolper  the 
fifth  dorsal  vertebra  was  the  seat  of  a  carcinoma  : 

The  patieut,  a  man  forty-six  years  of  age,  had  recovered  one  month 
previously  from  a  pleurisy  Irom  which  he  had  suffered  for  six  months, 
when  he  was  again  taken  to  the  liospital  for  tumor  of  the  ribs.  Three 
days  hiter  there  was  paralysis  of  sensation  in  both  lower  extremities, 
especially  in  the  right  one.  Two  days  later  the  paralysis  of  sensation 
had  extended  upward  as  far  as  the  seventh  rib.  Motor  paralysis  of 
the  lower  extremities  was  manifested  soon  afterward,  with  retention 
of  urine,  constipation,  and  cystitis.  Death  occurred  in  forty-four  days. 

Traumatic   Inflammation    of    the    Neuroglia   and   Traumatic 
Syringomyelia. 

As  a  result  of  injuries  of  the  cord  a  growth  of  cicatri- 
cial tissue  takes  place,  involving  the  supporting  frame- 
work— the  neuroglia — as  well  as  the  connective  tissue  of 
the  l)lood- vessels.  This  hyperplasia  of  the  neuroglia 
may  be  based  on  a  congenital  tendency.  It  is  often  the 
precursor  of  destruction  of  the  cord-substance  and  of 
cavity  formation — syringomyelia.  Syringomyelia  may 
also  be  directly  caused  by  traumatism.  It  is  most  fre- 
quently found  in  the  cervical  region. 

According  to  Wagner  and  Stolper,  the  following  })oints 
are  of  assistance  in  determining  the  traumatic  origin  of 
syringomyelia  : 

1.  Signsof  a  healed  fracture  or  dislocation  found  in  the 
vertebroe  point  to  traumatism.  During  life  kyphosis  is 
frequently  seen,  while  scoliosis  is  more  characteristic  of 
the  nontraumatic  form. 

2.  Traumatic  syringomyelia  is  most  frequently  seen  in 
the  regions  especially  subject  to  fracture  :  i.  e.,  the  lower 
dorsal  and  lumbar  regions  ;  the  nontraumatic  form  is 
more  likely  to  occur  in  the  cervical  region. 


TEA  UMA  TIC  S  YRINGOMYELIA .  175 

3.  In  traumatic  syringomyelia  we  are  likely  to  find 
adhesions  and  hyj^ortrojihy  of  the  meninges,  both  with 
each  other  and  M'itli  the  wall  of  the  vertebral  canal. 
Some  exogenous  cause  is  likely  to  be  discovered,  whereas 
in  the  nontraumatic  form  of  syringomyelia,  which  de- 
velops as  the  result  of  a  central  hyperplasia  or  destruc- 
tion of  the  neuroglia,  this  is  not  the  case.  For  the  same 
reason  we  find  a  proliferation  of  the  pia  mater  in  the  one 
case,  but  not  in  the  other. 

4.  In  traumatic  cases  the  cavity  is  likely  to  be  situated 
in  the  posterior  columns  ;  otherwise  it  is  found  only  in  the 
anterior  horns  ;  in  the  nontraumatic  form  the  posterior 
commissure  is  the  favorite  site. 

5.  In  the  traumatic  form  blood-pigment  is  often  found  ; 
its  presence  can  not  be  explained  on  the  ground  of  idio- 
pathic aftection  of  the  blood-vessels,  which  is,  as  a  rule, 
seen  in  connection  with  the  nontraiunatic  form. 

An  ascending  neuritis,  occurring  in  consequence  of  a 
peripheral  injury,  is  said  in  some  cases  to  be  followed  by 
syringomyelia. 

Symptoms. — Localized  ^ympioms: 

[We  are  hardly  in  a  position  as  yet  to  speak  of  trau- 
matic syringomyelia.  There  are  two  possibilities.  One 
is  that  a  trauma,  by  causing  hemorrhage  into  central  gray 
matter  that  is  already  diseased,  calls  forth  into  activity  a 
latent  myelosyringosis.  The  other  possibility  is  that  cen- 
tral hematomyelia,  as  described  in  the  note  on  page  135, 
may  cause  permanent  sym])toms  similar  to  those  of  syrin- 
gomyelia. But  neither  possibility  would  justify  the  term 
"traumatic  syringomyelia."  For,  in  the  first,  the  trauma 
would  be  merely  a  contributory  cause ;  and  the  second, 
while  it  might  in  its  symptomatology  be  identical  with 
syringomyelia,  would  l)e  so  different  in  pathogenesis  that 
nothing  would  be  gained  by  giving  it  the  name  of  a 
chronic  progressive  disease  when  its  own  name  of  trau- 
matic hematomyelia  so  well  describes  it. — Ed.] 

1.   Progressive    paralysis    and    muscular    atrophy,    in- 


176  DISEASES  CAUSED   BY  ACCIDENTS. 

volving  one  or  both  sides.  In  nontraumatic  cases  the 
upper  extremities  are  especially  involved.  The  atrophy 
is  of  the  degenerative  type ;  fibrillary  spasms  can  be 
observed,  and  the  electric  reaction  is  that  of  degeneration. 

2.  Disturbances  of  sensation.  The  tactile  sense  re- 
mains unaifected,  while  analgesia  and  thermal  anesthesia 
are  manifested  ;  burns  are  not  felt. 

3.  Trophic  disturbances  of  the  fingers,  of  the  feet,  and 
of  the  corresponding  joints,  and  of  the  nails;  contractures 
and  rigidities  ;  formation  of  ulcers. 

4.  Paralysis  of  the  bladder  and  rectum,  impotence, 
etc. 

Case  of  syringomyelia  foUowinff  cellulitis  of  the  forearm  and  ascending 
neuritis. 

A  workman,  twenty -nine  years  of  age  (alcoholic),  was  injured  in 
his  left  forearm  near  the  elhow-joint  by  the  penetration  of  a  piece 
of  wire,  on  August  9,  1895.  His  arm  was  treated  for  one  week  with 
wet  dressings,  incision  then  being  practised  on  account  of  marked 
swelling  and  fever.  I  examined  the  patient  November  9,  1895.  His 
left  elbow  was  fixed  in  a  position  of  slight  flexion  ;  the  scar  on  its  ex- 
tensor surface  was  not  quite  healed  and  was  still  suppurating.  The 
left  arm  was  considerably  wasted,  especially  the  hand. 

Treatment  was  first  directed  to  the  wound  ;  then  to  the  contracture 
of  the  joint. 

Neuritic  .symptoms  gradually  manifested  themselves,  at  first  in  the 
forearm,  then  ascending  as  far  as  the  shoulder.  The  whole  arm  was 
the  seat  of  severe  pain,  which  also  extended  to  the  shoulder  and  to 
the  whole  leftside  of  the  throat  and  neck.  There  was  pain  on  motion 
of  the  head  and  on  attempts  to  rai.se  the  arm  ;  also  tremor  in  arm  and 
hand.  The  patient  closed  his  hand  with  great  difficulty,  and  was  un- 
able to  grasp  anything  tightly.  Atrophy  of  the  nails  began  to  appear, 
and  the  distal  phalanges  showed  signs  of  stiffne.ss,  while  the  muscles 
of  the  hand  were  greatly  wasted.  There  were,  in  addition,  thermal 
anesthesia,  necrotic  ulcers  on  the  fingers,  tremor  of  the  facial  muscles 
on  the  left  side,  marked  dilatation  of  both  pupils,  and  diminution  of 
the  pupillary  reflex.     Insurance  allowance,  60%. 

Tn  multiple  sclerosis  we  have  another  disease  giving 
localized  symptoms,  in  which  sclerotic  patches  are  foinid 
scattered  through  both  the  brain  and  the  cord ;  it  is 
observed  as  a  sequel  of  either  central  or  perijiheral 
traumatism.  The  symptoms  are  somewhat  variable,  as 
may  be   expected  from   the   irregular  distribution  of  the 


SPASTIC  PARAPLEGIA.  Ill 

lesion.  They  include  :  Disturbances  of  speech  ;  a  slow, 
scanning,  and  monotonous  manner  of  speaking ;  nystag- 
mus ;  exaggerated  reflexes  ;  spastic  and  ataxic  gait ;  in- 
tention tremor ;  and  uncertain,  exaggerated  movements. 
The  treatment  is  symptomatic. 

Chronic  Progressive  Anterior  Poliomyelitis. 

Disease  of  the  anterior  horns  may  l)e  due  to  injuries 
and  diseases  of  the  central  nervous  system,  or  it  may 
follow  an  ascending  neuritis.  Tlie  muscles  supplied  by  the 
diseased  parts  undergo  atrophy,  but  respond  to  the  will  as 
long  as  any  muscle-fibers  are  left.  The  reflexes  are 
diminished  but  not  abolished.  The  application  of  cold  to 
the  skin  (sometimes  blowing  on  it  will  suffice)  induces 
slight  spasms  in  the  affected  muscles,  involving  only 
separate  bundles  or  fibers,  which  are  to  be  looked  u[)on, ' 
according  to  Leube,  as  pathologic  reflex  contractions 
(Thiem). 

The  skin  of  the  affected  region  is  reddened  or  bluish-, 
red,  and  occasionally  shows  a  vesicular  eruption.      A  cer- 
tain amount  of  improvement  may  take  place  ;  the  prog- 
nosis, therefore,  is  not  entirely  unfavorable. 

Spastic  Paraplegia. 

[In  many  of  the  cases  to  which  this  clinical  term  is  given  the 
underlying  lesion  is  probably  multiple  sclerosis. — ^Ed. ] 

In  this  affection  of  the  cord,  which  may  follow  either 
central  or  peripheral  lesions,  the  lateral  ])yramidal  tracts 
are  involved.  We  have,  therefore,  the  following  symp- 
toms :  exaggerated  reflexes  and  diminished  muscular 
power,  without  atrophy  or   degeneration. 

If  in  the  course  of  time  the  process  extends  to  and  in- 
volves the  anterior  horns,  atrophy  will,  of  course,  result. 
The  first  symptoms  to  be  manifested  are  weakness  and 
atrophy  of  the  muscles  of  the  hand.  The  spastic  paresis 
characterizing  the  gait  is  seldom  noticeable  until  some 
time  later.  The  atrophy  extends  upward  to  the  shoul- 
12 


178  DISEASES  CAUSED  BY  ACCIDENTS. 

der ;  the  muscles  soon  show  fibrillary  contractions  and 
the  reaction  of  degeneration,  while  the  reflexes  become 
exaggerated.  The  patellar  reflex  is  likewise  afl'ected ; 
foot-clonus  and  bulbar  symptoms  also  develop. 

Tabes  Dorsalis ;  Locomotor  Ataxia. 

[Much  the  same  difficulty  as  was  described  for  general 
paresis  is  met  with  in  the  attempt  to  fix  a  traumatic  causa- 
tion for  locomotor  ataxia.  Tabes  is  very  insidious  in 
its  onset,  and  most  of  the  early  symptoms  are  of  a  char- 
acter that  no  one  but  the  physician  familiar  with  nervous 
diseases  would  recognize.  There  is  no  room  for  doubt  that 
injuries  often  first  bring  the  disease  to  the  notice  of  the 
patient,  or  that  through  injury  it  becomes  very  much 
worse.  But  to  show  that  an  injury  is  the  sole  cause  of 
it,  in  the  seuse  that  without  the  injury  the  disease  would 
not  have  occurred,  will  rarely  be  possible. — Ed.] 

As  a  result  of  traumatism  this  disease,  which  may  have 
been  in  existence  for  a  number  of  years  without  noticeable 
manifestation,  is  suddenly  awakened  into  activity  and 
makes  rapid  progress  in  its  development.  Since  marked 
tabetic  symptoms  in  such  cases  do  not  appear  until  after 
the  injury,  the  term  "  traumatic  tabes "  is  not  altogether 
out  of  place.  The  cases  referred  to  later  are  interesting 
in  this  connection,  no  tabetic  symptoms  whatever  having 
been  manifested,  or  at  least  noticed,  previous  to  injury. 

The  exciting  traumatism  may  act  either  centrally  or 
peripherally. 

Instances  of  central  injuries  are  :  hemorrhages  into  the 
substance  of  the  cord  (from  concussion  of  the  cord  (?)),  con- 
tusions, and  dislocations  or  fractures  of  the  spine  involv- 
ing lesion  of  the  cord.  To  the  peripheral  causes  belong  : 
sprains,  dislocations,  and  fractures  of  the  ankle-joint  or  of 
any  part  of  the  lower  extremity,  severe  contusions,  and 
phlegmonous  inflammations. 

The  patient  need  not  be  completely  incapacitated  for 
self-support,  even  in  cases  presenting  definite  tabetic  symp- 


LOCOMOTOR  ATAXIA.  179 

toms ;  complete  incapacity  is  not  tp  be  recognized  until 
the  symptoms  become  quite  marked  and  until  the  charac- 
teristic gait  is  well  developed. 

The  most  important  symptoms  are :  (1)  Loss  of  pupil 
reflex  ;  (2)  loss  of  patellar  reflex  ;  (3)  ataxia  (uncertain, 
stamping  gait ;  unsteadiness  on  closing  the  eyes). 

The  disease  is- further  characterized  in  its  diflerent 
stages  by  paralytic  disturbances  of  sensation  and  of  the 
functions  of  the  bladder,  severe  pains,  vomiting,  cough, 
difficulty  in  breathing,  ocular  paralysis,  etc. 
.  In  respect  to  treatment,  some  improvement  may  be 
gained  from  antisyphilitic  remedies,  the  underlying  cause 
of  the  disease  being  specific  in  the  majority  of  cases. 
Gymnastic  treatment  has  been  highly  praised  in  the  last 
few  years  ;  baths  and  nerve  tonics  may  also  prove  bene- 
ficial. Recovery  is,  however,  out  of  the  question  ;  the 
progress  of  the  disease  can  not  be  arrested. 

The  arthropathies  seen  in  cases  of  tabes  have  already 
been  referred  to  in  the  first  part  of  the  book. 

Case  of  locomoior  ataxia  following  ^^  concussion  of  the  spinal  cord.^' 

A  carjjenter,  fifty-two  years  of  age,  fell  from  a  building  on 
November  14,  1891,  striking  on  his  back.  He  was  first  treated  at 
home  by  his  lodge  physician,  and  by  him  sent  to  a  nerve  specialist, 
who  treated  him  for  "  Inmbago."  He  was  next  cared  for  at  home  by 
a  doctor  who  i'ound  him  in  bed  with  fever  and  made  a  diagnosis  of 
"  influenza."  The  physician  into  whose  charge  he  next  fell  diagnosed 
pulmonary  phthisis.  Finally,  in  the  hospital,  a  diagnosis  was  made 
of  incipient  tabes,  based  on  the  following  symptoms  :  loss  of  pupillary 
reflex  (pupils  much  contracteil),  marked  swaying  of  the  body  on  clos- 
ure of  the  eyes,  and  loss  of  the  patellar  reflexes. 

I  examined  the  patient  February  19,  1892.  He  was  a  small,  pale- 
faced  man.  In  addition  to  the  symptoms  mentioned,  he  frequeutly 
suffered  from  incontinence  of  urine  and  from  diarrhea.  He  declares 
that  he  was  always  well  prior  U^  his  accident.  His  condition  has 
remained  unchanged  up  to  date.     Insurance  allowance,  100  fo. 

Case  of  locomotor  ataxia   following  a  sprained  ankle. 

A  mason,  thirty-nine  years  of  age,  sprang  from  a  scaffolding  on 
Novenil)er  4,  1893,  in  order  to  save  himself  from  a  severe  accident 
that  would  otherwise  have  followed  a  misstep.  He  landed  with  his 
right  foot  on  a  stone  slab,  striking  his  head  against  a  wall.  He  imme- 
diatfly  passed  a  large  quantity  of  urine.  He  was  taken  home,  where 
he  lay  in  bed  and  was  treated  for  a  sprained  ankle.  Four  weeks  later 
he  attempted  to  walk,  and  his  peculiar  gait  was  at  once  noticed  by  his 


180  DISEASES   CA  USED  BY  A CCIDENTS. 

family.  Tlie  doctor  diagnosed  the  case  as  one  of  tabes.  The  patient 
is  said  to  have  previously  suftered  from  syphilis. 

I  examined  him  Fel)ruary  26,  1894,  and  made  the  following  diag- 
nosis :  locomotor  ataxia  Ibllowiug  peiipheral  traumatism,  consisting 
of  a  sprain  of  the  right  ankle.  Arthropathy  of  the  right  foot.  In- 
surance allowance,  lOO'/c.     No  change  in  his  condition  up  to  date. 

Case  of  prccxistiiif/  hwomotor  ataxia,  the  progress  of  ivhich  was  greatly 
accelerated  hij  fracture  of  the  le;/,  caused  Inj  a  misstep  upon  a  sharp  stone. 
Sequel,  complete  incapacity  for  self-support. 

A  mason,  forty-six  years  of  age,  stepped  on  a  sharp  stone  on  Janu- 
ary 20,  1897  causing  his  leg  to  give  way  and  throwing  him  to  the 
ground.  A  fnictnre  of  the  left  leg  was  diagnosed  and  appropriate 
treatment  was  begun. 

I  examined  him  March  6,  1897.  He  was  a  man  of  medium  height 
and  vigorous  l)uild  ;  his  gait  was  markedly  ataxic.  Tlie  pupils  were 
small  and  did  not  react  ;  patellar  reflexes  were  lost.  On  closing  his 
eyes,  even  when  sitting,  there  was  marked  swaying  of  the  body. 
Diagnosis,  locomotor  ataxia.  The  patient  had  had  sy))liilis  twenty 
years  earlier  ;  he  was  married,  but  had  no  children.  In  1896  he  had 
suffered  from  "  rlienmatism  "  in  his  arms  and  legs  for  eight  weeks. 
At  that  time  he  began  to  notice  unsteadiness  of  gait,  but  was  able  to 
work,  even  on  scaffohlings.  Since  his  accident  he  has  been  completely 
incapacitated  for  sell-support.  His  insurance  allowance  ecjualed  33j% 
at  first;  later,  it  was  raised  to  66'^%  by  legal  process.  The  fact  of 
the  precxistence  of  the  disease  was  taken  into  consideration. 

Cases  of  paralysis  agitans  can  occasionally  be  traced 
directly  to  an  injury  ;  the  case  of  my  own  given  later  is  an 
instance  of  such  relation.  The  aftection,  which  is  peculiar 
to  middle  and  old  age,  presents  characteristic  symptoms. 
The  patient  holds  his  body  bent  forward  in  a  crouching 
posture,  while  one  forearm  is  in  a  state  of  constant  tremor. 
The  tremor  ceases  during  sleep  or  when  the  patient  is  rest- 
ing quietly,  but  is  induced  and  increased  by  excitement. 
There  may  be  a  temporary  lull  in  the  symjitoms,  simulat- 
ing an  improvement.  By  reason  of  the  age  of  the  patients 
they  are  usually  rendered  incapable  of  self-support. 

Case  of  paralysis  agitans  following  fracture  of  the  ribs  and  contusion 
of  the  spine. 

On  October  24,  1888,  a  workman,  sixty  years  of  age,  slipped  and  fell 
to  the  ground,  striking  his  l)ack  against  the  edge  of  a  wheelt)arrow. 
Four  weeks  later,  when  union  had  taken  place  in  the  broken  ribs,  he 
noticed  the  first  symptoms  of  nervous  disease,  which  I  diagno.sed 
as  paralysis  agitans  on  January  18,  1889.  The  traumatic  etiology 
was  recognized,  and  100%  insurance  was  allowed.  The  condition  of 
the  patient  has  remained  unchanged. 


TBA  UMA  TIC  NEURASTHENIA.  181 


Spinal  Irritability ;    Spinal  Neurasthenia. 

The  classic  researches  of  Wagner  and  Stolper  have  cast 
a  donbt  upon  the  traumatic  origin  of  this  atfection,  and, 
indeed,  upon  its  very  existence.  The  symptoms  that  have 
been  considered  to  belong  to  it — pain  in  the  back  and 
loins,  sensitiveness  to  pressure  on  the  spine,  exaggerated 
reflexes — may  in  reality  l)e  the  forerunners  of  serious  dis- 
orders of  later  development.  If  not,  they  may  be  looked 
upon  as  symptoms  of  the  functional  neuroses.  In  the 
two  cases  of  Leyden  and  Schiitfer  cited  by  Thiem  there 
was  a  subsequent  development  of  tuberculosis. 

[This  is  contrary  to  the  teachings  and  experiences  of 
most  neurologists.  Traumatic  neurasthenia  is  generally 
accepted  as  the  best  name  for  certain  types  of  nervous 
exhaustion  that  are  frequently  the  results  of  accidents. 
In  such  cases  no  evidences  of  gross  structural  injury  to 
the  central  nervous  system  are  apparent  or  ever  become 
so.  The  symptoms  are  almost  identical  with  those  of 
neurasthenia  in  which  injury  has  had  no  part. — Ed.] 

Case  of  traumatic  neurasthenia  following  contusion  of  the  spine. 

A  man,  thirty-nine  years  of  age,  was  hit  in  the  back  by  the  pole 
of  an  omnibus  on  January  25,  1893.  He  was  treated  in  a  dispensary 
for  four  weeks,  then  in  the  hospital  for  two  weeks,  when  clinical  treat- 
ment was  resumed.  He  attempted  to  work,  but  was  obliged  to  stop 
on  account  of  pain  in  the  back.  He  has  not  worked  since  April  27, 
1893.     He  is  a  large  man  of  moderately  vigorous  build. 

Symptoms. — Depressed  expression  ;  easilj'  moved  to  tears  ;  restless- 
ness ;  insomnia  ;  dilated  pupils,  which  react  slowly.  The  spine  was 
sensitive  to  pressure  throughout  its  length,  and  especially  in  the  dorsal 
region  ;  it  was  fixed  on  every  attempt  at  motion.  The  reflexes  were 
exaggerated  ;  there  were  no  sensory  disturbances.  Examination  did 
not  give  definite  results.  The  gait  was  somewhat  dragging.  The 
patient's  condition  has  remained  unchanged  up  to  date.  He  lies  abed 
much  of  the  time,  and  can  not  be  induced  to  attempt  to  work. 

Case  of  traumatic  neurasthenia  of  a  hypochondriacal  character  follow- 
ing a  fall  from  a  height.     {Siniulntion  suspected.) 

A  roofer,  twenty-eight  years  of  age,  fell  from  the  roof  of  a  five- 
story  hon.se  on  October  11,  1889.  He  suffered  a  slight  concussion  of 
the  brain,  a  number  of  contusion-wounds,  and  a  sprain  of  the  right 
ankle.  He  was  treated  at  hoine,  lying  in  bed  for  four  weeks.  I  ex- 
amined him  January  15,  1890.     He  was  quite  a  large,  powerful  man, 


182  i)isl:A8Es  CA used  by  a CCIDENTS. 

of  rather  pale  complexion.  Hi?  expression  was  depressed,  hut  at  the 
same  time  surly  and  detiant.  Physical  examination  was  complained  of 
as  exceedingly  painful,  and  was  in  part  not  permitted.  There  seemed 
little  basis  for  the  innumerable  complaints  of  the  patient.  Although 
he  declared  himself  to  be  unable  to  do  work  of  any  kind,  he  is  known 
to  have  worked  as  a  roofer,  receiving  full  pay.  He  was  consequently 
declared  to  be  capable  of  self-suppoit,  but  subsequently  was  allowed 
25  fo  insurance  b}'  the  court. 

Case  of  traumatic  hysteria  of  a  hypocJionihiacaJ  character  fottowing 
contusion  of  the  sj)ine. 

A  mason,  forty-two  years  of  age,  was  struck  on  the  back  by  a 
heavy  stone,  which  iell  from  the  third  story,  on  April  18,  1887.  He 
felt  faint  and  discontinued  work.  He  was  treated  for  ten  days  in  the 
hospital,  and  was  then  discharged,  on  his  own  request,  as  cured. 

I  examined  him  on  July  19,  1887.  He  was  a  large,  rather  vigor- 
ously built  man.  He  held  his  body  somewhat  inclined  i'orward  ;  his 
expression  was  depressed,  and  his  eyes  had  a  somewhat  staring,  vacant 
look.  The  facial  muscles  were  noticeably  unmoved  when  he  spoke. 
The  spine  was  sensitive  to  pressure  and  was  fixed  on  motion  of 
the  body  ;  the  cutaneous  reflexes  and  tendon-reflexes  of  the  lower 
extremities  were  exaggerated;  there  was  a  tremor  in  the  latter  and 
muscular  weakness  in  the  arms.  Sensation  was  diminished  in  the 
right  leg  and  in  both  forearms  ;  there  was  anesthesia  to  pain  in  the 
same  parts.  The  pulse  was  exceedingly  ra])id.  The  patient  com- 
plained of  a  feeling  of  oi)pression  and  of  melancholy. 

His  subsequent  conduct  has  given  cause  for  much  displeasure  ;  he 
writes  threatening  and  complaining  letters  to  his  trades-union,  and 
considers  that  he  is  badly  treated  ])y  everybody.  Insurance  allow- 
ance, 100%.     He  has  done  no  work  since  his  accident. 

Contusion  and  Crushing  of  the  Back. 

In  preparing  the  following  I  have  made  use  of  seventy-eight  cases 
of  injuries  of  the  back  that  have  come  under  my  own  observation. 

Contusions  of  the  back  caused  by  falls,  kicks,  or  blows 
from  falling  objects  usually  give  no  trouble  after  the  hem- 
orrhagic extravasations  have  been  absorbed  and  the  ])ain 
has  disappeared.  Individuals  thus  injured  may  not  find 
it  necessary  to  interrupt  their  work  at  all,  and  in  any  case 
resume  it,  as  a  rule,  Avithin  two  to  three  weeks.  Severe 
cases  of  crushing,  such  as  are  seen  after  the  caving-in  of 
buildings,  demand  a  longer  course  of  treatment,  and  are 
followed  by  a  limitation  of  mobility  of  the  body,  affect- 
ing the  patient  for  a  considerable  period.  All  such  cases 
should  be  examined  with  the  greatest  care,  or  else  an 
injury  of  the  spine  may  be  overlooked. 


STBAINS  OF  THE  BACK.  183 


Wounds  and  Cicatrices  of  the  Back. 

Movement  of  the  body  nuiy  be  noticeably  limited  by 
the  cicatrices  that  follow  extensive  wounds  of  the  back. 
Stooping,  for  instance,  is  made  difficult  for  some  time  by 
sears  in  the  region  of  the  long  extensor  muscles  of  the 
back.  Treatment  should  be  directed  chiefly  toward 
obtaining  a  nonadherent,  movable  scar. 

Case  of  a  cicatrix  adherent  to  the  twelfth  rib  on  the  left  side,  consequent 
upon  a  punctured  wound  of  the  back,  complicated  by  lesion  of  the  kidney. 

A  carpenter  was  injured  on  August  2:5,  1898,  by  a  chisel,  which 
penetrated  his  back  on  throwing  his  sack  of  tools  over  his  shoulder. 
The  lesion  involved  the  left  kidnej'.  He  was  operated  upon  in  the 
hospital,  where  he  remaiued  for  three  weeks. 

I  examined  him  on  December  19,  1898,  and  found  the  kidneys  nor- 
mal. In  the  region  of  the  left  kidney  there  was  a  scar,  of  recent 
origin,  and  about  10  cm.  in  length,  which  ran  obliquely  across  the 
back.  It  was  attached  to  the  twelfth  rib  and  was  adherent  through- 
out ;  on  stooping,  the  scar  became  very  tense,  and  prevented  deep 
flexion  or  flexion  to  the  right  side.  The  muscles  of  the  leftside  of  the 
back  were  atrophied.     Insurance  allowance,  20%. 

On  May  10,  1898,  the  scar  was  found  to  be  paler,  nonadherent,  and 
freely  movable.  He  was  able  to  stoop  with  ease,  and  could  pursue  his 
trade  without  difficult}'.   He  showed  evidences  of  attempted  sinuilation. 

Burns  of  the  back  lead  to  the  growth  of  more  or  less 
extensive  scars,  according  to  the  size  and  intensity  of  the 
lesion.  When  recent,  these  scars  limit  mobility  to  a  con- 
siderable degree.  The  patients,  as  a  mle,  recover  full 
capacity  for  self-support.  Severe  cases,  however,  neces- 
sitate treatment  for  a  long  period. 

Strains  and  Lacerations  of  Muscles  and  Tendons. 

Under  this  title  are  described  various  painful  affections 
of  the  back,  usually  of  traumatic  origin,  the  pains  dating 
from  the  time  of  accident. 

It  is  quite  possible  for  laceration  of  muscle-fibers  to 
take  place  as  a  result  of  carrying  heavy  loads,  of  awkward 
movements,  of  carrying  a  load  on  one  shoulder,  or  even 
of  falling  on  the  back  on  rough  ground.  There  may  be 
almost  no  external  sign  of  injury,  yet  the  pain  may  be 


184  DISEASES  CAUSED  BY  ACCIDENTS. 

very  severe.  Sometimes  the  pninful  point  is  found  to  be 
swollen.  In  the  cases  marked  by  persistent  pain,  in  the 
absence  of  swelling  a  very  thorough  examination  is  indi- 
cated, in  view  of  a  possible  injury  to  the  spine,  such  as 
fracture  of  one  or  more  of  the  })rocesses  or  lacerations  of 
the  ligaments. 

In  all  cases  of  so-called  traiimatio  lumbago  exann'nation 
of  the  urine  for  })hosphates  is  strongly  to  be  recommended, 
since  phosphaturia  frequently  causes  the  symptoms  of 
lumbago.  It  is  undoubtedly  a  fact  that  lumbago  may  de- 
velop after  traumatism,  giving  rise  to  the  ])ains,  commonly 
of  a  rheumatic  nature,  that  suddenly  attack  the  patient  in 
the  shape  of  a  "  crick  in  the  back."  The  same  symptoms 
may  be  due  to  direct  contusions  of  the  sensory  spinal 
nerves  or  of  their  roots.  The  ])ains  in  the  loins  may  be 
so  severe  as  almost  to  prevent  the  patient  from  moving. 
In  less  severe  cases  the  fixation  of  the  spine,  giving  a 
stiff  a])pearance  to  the  patient,  is  very  noticeable ;  also 
the  inability  to  stoop  or  to  rise  from  a  sitting  ])osture 
without  the  aid  of  the  hands.  Reference  has  already 
been  made  to  the  sprains  of  the  articular  processes  of  the 
fifth  lumbar  vertebra,  which  are  momentarily  forced  into 
the  lumbosacral  fossa.  The  lifting  of  heavy  weights 
sometimes  gives  rise  to  symptoms  that  are  indicative  of  a 
lesion  of  the  ligaments  in  this  situation,  and  that  are 
entirely  similar  to  those  of  luml)ago. 

Subcutaneous  rupture  of  muscles  has  been  observed  in 
the  long  muscles  of  the  back,  in  the  erector  s])inie  and 
also  in  the  latissimus  dorsi.  The  cause  of  this  injury  is 
not  definitely  understood.  In  the  cases  that  I  have  seen 
in  which  the  erector  spinre  Avas  ru])tured  by  a  fall  on  the 
back  the  point  of  ru])ture  was  plainly  visible.  The  lower 
part  of  the  muscle  had  retracted,  forming  a  thick  roll, 
while  the  overlying  muscles  were  distinctly  atrophied. 
Stooping  was  painful  at  first,  but  was  easily  accom])lished 
later  on.  In  one  case,  in  which  the  muscle  Avas  ruj)tured 
on  both  sides,  a  depression  could   be   plainly  felt  running 


Fig.  24. 


186  DISEASES   CAUSED  BY  ACCIDENTS 

almost  transversely  across  the  buck.  Stooping  was  so 
painfnl  that  it  was  not  attempted  at  first,  but  improve- 
ment was  evident  at  the  end  of  two  months.  The  insur- 
ance allowance  in  this  case  was  20^.  In  a  case  of  rup- 
ture of  the  latissimus  dorsi  cited  by  Thiem  it  was  very 
difficult  for  the  patient  to  raise  his  arm  or  to  place  it 
behind  his  back.  He  recovered,  however,  by  the  use  of 
baths,  massage,  and  electricity. 


III.  INJURIES  AND  TRAUMATIC  DISEASES  OF 
THE  CHEST. 

AnatomicopJiysiologic  Considerations. — Deformities  of  tlie  tliorax, 
apart  from  congeuital  abnormalities  or  those  acquired  through  disease, 
are  often  observed  in  workmen  as  the  result  of  special  forms  of  work. 
Reference  has  already  been  made  to  the  exaggerated  convexity  of  that 
side  of  the  thorax  on  which  the  load  is  carried  as  part  of  the  deformity 
characterizing  stone-carriers.  In  addition  to  the  convexity,  the  ribs  are 
usually  separated  on  that  side,  while  on  the  other  the  thorax  is  de- 
pressed and  the  ribs  are  approximated.  The  shape  of  the  thorax  may 
also  undergo  modification  in  consequence  of  a  regularly  maintained 
position  of  the  body.  In  examining  patients  these  facts  should 
always  be  borne  in  mind  or  serious  errors  may  result. 

Although  familiarity  with  all  the  deformities  due  to  work  in  the 
various  branches  of  industry  is  hardly  possible,  we  should,  neverthe- 
less, make  detailed  inquiry  into  the  employment  of  the  patient,  in 
order  that  a  differential  diagnosis  ))etween  deformities  iucidental  to 
such  employment  and  the  sequels  of  traumatism  may  be  made.  If 
we  watch  the  thorax  during  respiration  and  during  movements  of  the 
body, — fiexion,  extension,  and  rotation, — we  can  observe  differeuces 
in  the  action  of  the  ribs  on  the  two  sides. 

A  few  words  in  I'espect  to  the  term  chest  as  understood  by  work- 
men will  not  be  out  of  place  here.  It  is  used  l)y  them  to  describe 
not  only  the  anterior  bony  wall  of  the  thorax,  ])ut  also  the  adjacent 
part  of  the  abdomen.  It  is,  indeed,  almost  impossible  to  draw  a  sharp 
line  between  the  two  regions  externally,  since  a  not  inconsiderable 
part  of  the  abdominal  organs  are  contained  in  the  thorax.  A  special 
section  being  devoted  to  injuries  of  the  former,  they  will  be  left  out 
of  consideration  in  discussing  those  of  the  chest,  and  will  be  referred 
to  only  when  absolutely  necessary.  The  thoracic  and  abdominal  cavi- 
ties, although  divided  by  the  diaphragm,  bear  a  very  close  and  inter- 
dependent relation  to  each  other,  as  we  know  from  a  study  of  their 
anatomy  and  physiology. 

The  relation  of  the  thorax  to  the  upper  extremities  is  also  extremely 
important  in  regard  to  the  effects  of  traumatism.     Injury  of  the  mus- 


CONTUSIOA^S   OF  THE   THORAX.  l87 

cles  of  the  tliorax  or  of  the  arm  may  seriously  hamper  the  fnuctional 
action  of  other  parts,  or  even  disable  them  altogether.  The  mutual 
interdependence  of  the  different  regions  of  the  l)ody  and  their  rela- 
tions with  ueighltoring  organs  should  always  be  kept  in  mind  in  deal- 
ing with  accident-cases. 

My  material  embraces  4"36  cases  of  injury  of  the  thorax — 227  cases 
of  contusions,  184  of  fracture  of  the  ribs,  and  15  of  internal  injuries. 


CONTUSIONS  OF  THE  THORAX. 

In  the  majority  of  cases  slight  contusions  of  the  wall 
of  the  thorax,  caused  by  falls,  kicks,  or  blows,  heal  rap- 
idly and  without  sequels,  necessitating  only  a  day  or  two 
of  rest.  Some  of  the  patients  simply  have  a  few  cups 
applied  and  resimie  work  on  the  following  day.  The 
symptoms  may,  however,  persist  somewhat  longer,  involv- 
ing a  course  of  treatment  of  several  weeks'  duration. 
Severe  contusions,  on  the  other  hand,  or  even  slight  in- 
juries to  individuals  sutfering  from  an  affection  of  the 
lungs,  cause  disturbances  that  may  persist  for  some 
months,  or  even  longer,  in  spite  of  treatment. 

Symptoms. — Pains  in  the  chest,  which  are  often  diffi- 
cult to  locate  with  exactness,  dyspnea,  palpitation  of  the 
heart,  weakness,  inability  to  stoop  or  to  lift  w^eights,  fre- 
quency of  anorexia,  etc. 

On  examination  we  may  find  affections  of  the  pleura 
(dullness,  diminished  res[)iratory  sounds,  friction-sounds, 
more  or  less  circumscribed  tenderness)  or  of  the  lungs 
(traumatic  pneumonia)  ;  also  affections  of  the  pericardium 
or  of  the  cardiac  muscle,  of  the  stomach,  or  of  the  liver. 
We  may  find,  in  short,  a  number  of  morbid  conditions 
that  were  not  noticed  at  first,  since  their  onset  was  gradual, 
but  that  were  made  evident  and  aggravated  by  a  too  early 
resumption  of  work.  AVe  shall  refer  again  to  these 
symptoms. 

Since  severe  contusions  may  cause  laceration  of  the 
thoracic  organs,  it  is  only  to  be  expected  that  similar  but 
more  severe  lesions  should  occur  in  the  peculiar  cases  of 
crushing  of  the   thorax  with  which   we  meet  in  patients 


1<S8  DISEASES   CAUSED   BY  ACCIDENTS. 


PLATE  10. 

Fig.  1. — Case  of  Compound  Fracture  of  the  Sternum  and  the 

First  Rib  on  the  Left  Side.  ,Se(juel,  complete  recovery  except  for 
slightly  (liniinislied  capacity  for  self-support. 

The  illustration  shows  the  scar  on  the  sternum.  The  patient  was 
a  stone-carrier,  forty-live  years  of  age,  who,  on  October  7,  1892,  was 
injured  by  the  breaking  of  his  hod,  being  knocked  down  and  struck 
on  the  chest  hj  the  stones  that  the  hod  contained.  He  was  treated  in 
the  hospital  for  three  months,  the  fractured  bone  being  united  by 
sutures.  I  examined  him  March  6,  1893.  He  was  a  large,  vigorous 
man.  On  deep  respiration  he  complained  of  pain.  For  a  short  time 
he  was  treated  in  my  hospital  by  mechanical  methods  (chest-expan- 
sion), and  was  then  discharged  with  an  insurance  allowance  of  15%, 
later  increased  to  25%.  He  does  not  consider  himself  able  to  carry 
stones. 

Fici^.  2. — Case  of  Ununited  Indirect  Fracture  of  the  Seventh 
Rib  on  the  Left  Side.     The  working-capacity  is  relatively  good. 

The  illustration  shows  a  small,  round  tumor  on  the  seventh  rib, 
clo.se  to  the  mammillary  line.  It  does  not  protrude  sharply.  A  man, 
forty  years  of  age,  fell  from  a  ladder  on  December  30,  1897,  striking 
on  his  right  hip.  He  at  once  felt  pain  in  the  left  side  of  the  chest, 
and  remained  in  bed  for  four  weeks,  being  treated  by  plaster  strips 
and  compresses.  I  examined  him  March  24,  1898.  He  complained 
of  stabbing  pain  in  the  left  side  of  the  chest  and  of  dyspnea  on  climl)- 
ing  stairs.  I  found  a  small,  round,  fairly  movalde  tumor  on  the 
seventh  rib  on  the  left  side,  filling  the  space  between  that  and  the 
sixth  rib.  It  was  still  red  in  appearance.  Pressure  on  the  fractured 
segments  of  the  bone  produced  crepitation.  The  tumor  was  pushed 
forward  on  coughing.  On  auscultation  there  were  slight  dullness  and 
a  few  pleuritic  friction-.sounds.  The  insurance  allowance  was  fixed  at 
20%,  in  view  of  the  fact  that  he  was  able  to  work  at  full  wages.  He 
was  subsequently  allowed  33^%  by  the  court,  which  allowance  was 
reduced  four  montlis  later  to  20%. 


who  liavc  been  run  over  or  caught  between  car-buiFers,  or 
under  fallino-  walls,  heavy  beams,  and  the  like.  Such 
injuries  often  ])roduce  fractures,  but  it  not  infrequently 
liappens,  especially  in  young  and  healthy  individuals,  that 
the  thorax  is  crushed  in  without  breaking  a  single  rib. 
The  internal  organs  ai'e  almost  always  lacerated  in  such 
cases,  and  death  is  liable  to  occur  immediately  or  very 
soon  afterward.  When  the  injury  does  not  terminate 
fatally,  it  frequently  leads  to  aifections  of  the  lacerated 
organs,  and  the  patient  is,  in  consequence,  partly  or 
wholly  incapacitated  for  self-support. 


^^MiuiRlf'RMMEutTfflfttVMr,  >.  -^ 


^ 


i 


i 


Fig.  25. 


190  DISEASES  CAUSED   BY  ACCIDENTS. 

Case  of  fracture  and  crushing  of  several  ribs  on  the  right  side.  Sequel, 
perfect  recovery. 

A  coachman,  forty-six  years  of  age,  was  thrown  from  the  seat 
of  his  carriage  on  January  4,  1898,  the  hind  wheel  passing  over  his 
chest.  On  examination  a  definite  diagnosis  of  fracture  could  he  made 
only  in  respect  to  tlie  seventh  rib  on  the  right  side.  On  February  7, 
1898,  examination  showed  a  fibrous  pleuri,sy  of  the  right  side.  He 
was  allowed  30%  insurance.  On  March  8,  1899,  he  was  declared  to 
be  perfectly  capable  of  self-support. 

Case  of  severe  crmhing  of  thr  right  side  of  the  thorax  and  right  shoulder, 
complicnied  by  fracture  of  the  ribs  and  injury  of  the  lung.  Sequels  :  pul- 
monary tuberculosis  and  complete  paralysis  of  the  right  arm,  right 
shoulder,  and  right  side  of  the  thorax. 

A  man,  twenty-seveu  years  of  age,  was  caught  under  a  falling  build- 
ing, sustaining  the  foregoing  injuries.  The  injury  of  the  lung  was  at 
once  followed  by  pneumonia,  requiring  treatment  for  a  long  time  ; 
later,  tuberculosis  is  developed,  but  was  brought  to  a  standstill  by 
treatment  in  a  sanitarium.  His  right  arm  is  completely  paralyzed, 
and  is  cyanotic  and  cold  ;  the  right  side  of  the  thorax  is  also  para- 
lyzed ;  its  expansion  is  restricted  ;  no  respiratory  sounds  are  percepti- 
ble on  that  side,  and  the  muscles  of  tlie  right  side  of  the  chest  and 
back  are  greatly  atrophied.     Insurance  allowance,  100%. 

Fig.  25. — Case  of  severe  crushing  of  the  thora.v  and  fracture  of  several 
ribs  (p.  189).     Sequels  :  chronic  pleurisy  ;  death  from  tuberculosis. 

A  man,  thirty-eight  years  of  age,  fell  to  the  ground  on  June  4,  189(>, 
in  such  a  way  as  to  cause  his  hod,  filled  with  lime,  to  strike  on  the  left 
side  of  his  chest.  He  was  treated  at  home  by  means  of  compresses 
and  medicine,  lying  in  bed  for  eleven  days.  On  November  6th  he 
resumed  work  ;  on  February  13,  1897,  he  was  obliged  to  cease  work 
again  on  account  of  pleuri-sy  on  the  left  side. 

I  examined  him  on  February  17,  1897.  He  was  a  large  man,  but 
greatly  wasted.  The  left  side  of  the  chest  at  the  level  of  the  fifth  to 
the  seventh  ribs,  inclusive,  was  deeply  depressed.  The  respiratory 
sounds  were  diminished  in  intensity  over  the  entire  left  side  of  the 
thorax,  and  at  the  area  of  depression  they  could  not  be  heard.  On 
inspiration  the  left  side  of  the  thorax  expanded  less  than  tlie  right ; 
movements  of  the  thorax  were  difficult.  A  second  examination,  on 
June  2,  1897,  showed  dyspnea,  cough,  and  loud  rales  over  the  left 
apex.  The  patient  was  exceedingly  emaciated.  He  died  of  pulmonary 
tuberculosis  on  September  28,  1897. 

COMMOTFO  PECTORIS ;  CONCUSSION  OF  THE  CHEST. 

This  lesion  is  caused  by  severe  contusions,  and  is 
immediately  followed  by  unconsciousness.  In  severe  cases 
death  may  occur  at  once  ;  if  less  seriously  injured,  the 
patient  may  recover  from  the  shock  and  may  regain  his 
health  in  part  or  entirely.     Permanent  disturbances  may, 


WOUNDS   OF  THE   CHEST.  191 

however,  result,  such  as  very  severe  forms  of  hysteria, 
leading  to  complete  incapacity  for  work,  of  which  I  have 
myself  seen  several  instances. 

Case  of  commotio  pectoris,  followed  by  severe  hysteria,  tcifh  frequent  con- 
vulsions. 

A  mason,  forty  years  of  age,  fell  from  a  ladder  on  November  7, 1892, 
striking  with  his  chest  against  a  box  of  lime.  He  was  unconscious  for 
a  time,  but  was  afterward  aV)le  to  walk  home,  and  after  a  few  weeks 
of  medical  treatment  resumed  woi-k.  He  soon  found  himself  unable 
to  continue  work. 

I  examined  him  on  February'  6,  1893  ;  he  Avas  a  fairly  large,  vigor- 
ous man.  From  the  beginning  of  the  examination  he  was  greatly 
excited ;  there  ■s\as  marked  tremor  of  both  arms  and  legs,  first  on  one 
side,  then  on  the  other,  accompanied  1)y  facial  spasms  and  outbursts 
of  weeping.  Muscular  spasms  were  induced  by  examination  of  the 
reflexes  or  by  reference  to  tlie  consequences  of  the  accident.  The 
pupils  were  contracted  and  reaction  was  slow  on  both  sides.  Psychic- 
ally, he  exhibited  chronic  hypochondriacal  depression.  The  reflexes 
were  greatly  exaggerated.  In  testing  the  cremaster  reflex  on  the  left 
side  spasms  of  the  muscles  of  the  left  arm  were  immediately  induced. 
The  patient  was  completely  incapacitated  for  self-support ;  his  condi- 
tion has  remained  unchanged  uj)  to  date. 


WOUNDS  AND  CICATRICES  OF  THE  CHEST. 

The  degree  of  functional  disaljility  arising  from  cica- 
trices in  this  situation  depends  upon  the  size  and  loca- 
tion of  the  wound  as  well  as  upon  its  severity.  If  the 
cicatrix  is  extensive,  deeply  attached,  and  retracted,  and 
especially  if  it  is  adherent  to  one  or  more  ribs,  consider- 
able disability  may  result. 

The  usual  symptoms  consequent  upon  adhesions  to  the 
ribs  are  pain  and  a  feeling  of  tension  on  deep  inspiration, 
on  lifting  the  arm  on  the  atfected  side,  and  on  flexion  of 
the  body  away  from  the  latter.  The  muscles  often  undergo 
considerable  atrophy.  Fistulas  due  to  empyema  usually 
heal  with  deep,  circular,  and  nuich-retracted  scars,  which 
give  rise  to  symptoms  indicative  of  involvement  of  the 
diapliragm  or  the  intercostal  nerves.  The  symptoms 
gradually  diminish,  even  without  treatment.  They  can  be 
overcome  in  a  comparatively  short  time  by  menus  of 
mechanical  treatment. 


192  DISEASES   CAUSED  BY  ACCIDENTS. 

Cicatrices  resulting  from  l)urns  are  more  spread  out 
and  superficial,  and  do  not  cause  functional  disturbances 
unless  greatly  retracted  ;  mechanical  treatment — in  j)artic- 
ular  massage,  by  Avhich  the  scar-tissue  is  loosened  and 
stretched — is  also  of  great  benefit  in  these  cases. 

Ct(sc  of  severe  contusion  and  ineificd  wound  of  the  rif/hf  side  of  the  c/icst. 
Secjuel,  recovery,  with  extensive  cicatricial  growth  ami  limitation  of 
mobility  of  the  right  shonlder-joint. 

A  glazier,  twenty-se\'en  years  of  age,  was  caught  between  an 
overturned  glass  cupboard  and  a  door  on  January  6,  1899.  In  addi- 
tion to  the  severe  contusion  he  sustained,  he  was  pierced  in  the  right 
side  of  the  chest  liy  the  broken  glass.  He  was  treated  in  the  hosiiital 
for  five  weeks. 

1  examined  him  on  ISIarch  6,  1R99,  and  found  a  number  of  scars 
adherent  to  the  ribs  on  the  right  side  of  the  chest ;  the  muscles  of  the 
affected  region  were  git'atly  atrophied,  as  were  also  those  of  the  right 
arm.  The  latter  could  not  be  raised  at  the  shoulder-joint  to  more 
than  an  angle  of  9.")  degrees;  the  right  elbow-joint  showed  a  contrac- 
ture of  KJO  degrees. 

The  right  ai'ni  and  the  cicatrices  were  treated  by  massage.  ISIe- 
chanical  exercises  were  also  prescribed,  (^n  May  2d  the  patient  was 
discharged  from  the  clinic  because  of  disobedience  of  orders.  He  was 
then  able  to  raise  his  arm  to  an  angle  of  155  degrees,  and  the  mu.scles 
had  increased  in  size. 

The  pectoral  nmscles,  both  major  and  minor,  may  be 
ruptured  subcutancously  by  direct  or  indirect  \  iolence. 
The  lesion  occurs  in  cases  of  dislocation  of  the  humerus 
and  in  fractures  of  the  coracoid  process.  The  subclavius 
muscle  may  suffer  a  similar  injury  as  a  residt  of  fracture 
or  dislocation  of  the  clavicle  or  of  fracture  of  the  first  rib. 
The  muscles  are,  as  a  rule,  only  partly  involved,  but  com- 
plete ru])tures  of  the  pectoral  nuiscles  are  sometimes  seen 
in  patients  who  have  been  run  over  or  caught  under  fall- 
ing buildings,  walls,  etc.  The  remote  symj^toms  of  the 
lesion  are  a  depression  in  the  groove  of  Mohrenheim,  atro- 
phy of  the  muscles  of  tiie  chest,  shoulder,  and  arm,  and 
limited  mobility  of  the  latter.  Patients  complain  chit^fly 
of  pain  and  weakness  in  the  arm.  Ivupture  of  the  serra- 
tus  nuignus  is  sometimes  caused  by  exercises  on  the  hori- 
zontal bar.  This  muscle,  as  well  as  the  intercostals,  may 
also  be  partly  ruptured  in  cases  of  fracture  of  the  ribs. 


FRACTURES  OF  THE  STERNUM.  193 

Partial  ru})tures  are  best  treated  by  exercises,  baths, 
compresses,  massage,  and  electricity.  Complete  rupture 
of  the  pectorales  is  followed  by  permanent  functional  dis- 
ability. 

Case  of  partial  subcutaneous  rupture  of  the  pectoralis  major.  Sequel, 
improvement,  with  moderate  degree  of  functional  disability. 

A  mason,  thirty-eight  years  of  age,  was  engaged,  together  Avith 
several  fellow-workmen,  in  moving  an  iron  beam,  on  December  19, 

1893,  when,  in  consequence  of  the  blunder  of  the  others,  who  let  go  the 
beam  too  soon,  he  recei\ed  a  very  violent  and  painful  strain.  In  spite 
of  pain  in  the  right  side  of  the  chest  he  kept  on  A\ith  his  work  until 
December  2.'M.  He  treated  himself  for  several  days  with  compresses 
and  inunctions,  and  began  medical  treatment  on  December  '27th. 

I  examined  him  and  received  him  into  my  hosjjital  on  June  11, 

1894.  He  was  a  rather  large,  vigorous  man.  On  tlie  right  side  the 
chest  showed  atrophy,  and  there  was  a  marked  depression  in  the 
groove  of  IMohrenheim,  indicating  a  partial  rupture  of  the  pectoralis 
major.  The  right  deltoid,  biceps,  and  trapezius  were  atrophied  ;  the 
right  arm  could  be  raised  only  to  an  angle  of  95  degrees.  There  were 
a  tremor  of  the  right  arm  and  crepitation  in  the  lower  part  of  the 
cervical  spine  on  movement  of  the  heatl.  The  patient  was  discharged 
August  13,  1894,  and  was  considered  completely  capable  of  self-sup- 
port, there  being  only  slight  fvinctional  disability  at  this  time.  He 
was  later  allowed  20  %  by  the  court,  his  symptoms  having  again  in- 
creased. 

Fractures  of  the  sternum  are  unquestionably  a  rare 
form  of  injury.  They  may  be  caused  by  direct  violence, 
such  as  blows  from  falling  weights,  crushing  under  fall- 
ing walls,  and  similar  accidents,  or  by  indirect  violence. 
The  latter  mode  of  occurrence  is  met  with  in  cases  of 
fracture  of  the  bodies  of  the  vertebrae  from  overflexion, 
and  also  in  cases  of  similar  lesions  due  to  overextension. 

It  is  apparent  that  direct  fractures  of  the  sternum  in- 
volve greater  danger  than  the  indirect  form,  both  in  re- 
spect to  immediate  and  remote  consequences.  Symptoms 
due  to  changes  in  the  underlying  organs  that  were  injured 
at  the  time  of  accident  may  persist  for  a  long  time. 

Compound   fractures  of  the   sternum   are  followed   by 
cicatricial   adhesions,    which  are  likely   to   cause  pain  on 
vigorous  movenftnit  of  the  body,  on  carrying  loads,  or  with 
rapid  respiration, 
13 


194  DISEASES  CAUSED  BY  ACCIDENTS. 


FRACTURE  OF  THE  RIBS. 

I  have  treated  or  examined  184  cases  of  this  injury,  of  which  the 
majority  were  due  to  direct  violence.  In  a  nitnil)er  of  cases  direct  and 
indirect  fractures  occuired  simultaneously. 

In  order  to  obtain  a  clear  understanding  of  the  sequels 
of  fracture  of  the  ribs  it  is  imperative  to  keep  the  sha])e 
and  position  of  these  hones  clearly  in  mind.  Reference 
has  already  been  made  to  the  remarkable  elasticity  pos- 
sessed by  the  ribs,  by  means  of  which  they  are  able  to  en- 
dure great  pressure  without  giving  way.  When  the  limit 
of  this  elasticity  is  passed,  fracture  occurs. 

Direct  fractures  of  the  ribs  are  caused  by  kicks,  by 
blows  with  a  blunt  instrument,  or  l)v  falling  and  striking 
on  the  sharp  edge  of  a  wall,  table,  board,  step,  etc.  The 
fracture  occurs  at  the  point  at  which  the  violence  is  applied, 
the  fragments  of  bone  being  pressed  inward  while  the 
angle  of  fracture  lies  externally.  In  some  cases  one  of 
the  fractured  segments  is  displaced  outward,  subsequently 
forming  a  callous  thickening.  The  same  rib  may  simul- 
taneously suffer  an  indirect  fracture  at  another  point. 

The  fracture  may  be  complete  or  incomplete,  depending 
upon  the  degree  of  violence,  the  structure  of  the  ribs,  and 
the  age  of  the  individual.  Incomplete  fractures  are  very 
frequently  met  with,  and,  as  a  rule,  involve  the  internal 
surface  of  the  rib,  as  is  to  be  expected  if  we  considci*  that 
the  injury  is  usually  caused  by  direct  violence.  The  peri- 
osteum may  remain  intact,  even  if  the  rib  is  broken  in 
several  places. 

Fractures  of  the  rib  are  most  often  observed  in  indi- 
viduals of  advanced  years.  In  youth  the  ribs  possess  a 
high  degree  of  elasticity,  while  in  old  age  they  are  liable 
to  fracture  from  very  slight  causes.  Complete  fractures  are 
produced  l)y  the  same  causes  as  incomplete  fractures,  the 
violence  being  only  more  severe.  In  complete  fractures 
due  to  direct  violence  the  periosteum,  ih?  parietal  j^leura, 
the  pulmonary  pleura,  and  even  the  lung-tissue  itself,  are 


FRACTURE  OF  THE  RIBS.  195 

liable  to  be  penetrated  by  the  sharp  fragments  of  bone. 
In  some  cases  the  pericardium,  or  even  the  heart  itself, 
the  liver,  the  spleen,  or  the  kidneys  are  also  involved  in 
the  injury.  Bloody  sputum,  for  instance,  in  cases  of  direct 
fracture,  is  indicative  of  injury  to  the  pulmonary  tissue. 

Indirect  fractures  are  due  to  the  action  of  a  force  that 
causes  the  ribs  to  bend  to  a  degree  exceeding  their  flexi- 
bility. These  fractures  are  found  in  individuals  who 
have  been  crushed  between  car-buffers,  run  over,  etc. 
The  ribs  may  give  way  at  their  angle  or  at  their  weakest 
points  :  namely,  near  their  sternal  or  verteliral  attachment. 
Indirect  fractures  of  the  ribs  are  often  seen  in  connection 
with  fractnre  or  contusion  of  the  arm  consequent  upon  a 
fall,  the  arm  having  been  violently  forced  against  the 
thorax,  or  accompanying  contusion  of  the  clavicle  (in  the 
case  of  the  iirst  rib)  or  scapula.  The  ribs  are  often  broken 
in  connection  Avith  fracture  of  the  vertebrae — indirectly  in 
cases  involving  the  bodies  of  the  latter  directly,  as  a  rule, 
when  the  transverse  processes  are  concerned.  In  indirect 
fractures  the  bony  fragments  are  forced  outward.  This 
form  of  lesion  is,  therefore,  fraught  with  less  danger  to  the 
lungs  than  the  other — the  direct  form. 

INIuscular  action  alone  may  suffice  to  cause  fracture  of 
the  ribs.  A  number  of  cases  are  recorded  in  which  the 
fracture  was  due  to  coughing  or  sneezing  ;  F.  Baehr  has 
collected  twenty-four  such  cases  out  of  a  total  of  thirty- 
five  cases  caused  by  muscular  action.  In  most  instances 
such  accidents  undonljtedly  occur  in  old  persons,  or  as  a 
result  of  pathologic  processes  in  the  ribs.  Baehr,  however, 
cites  cases  of  fracture  caused  by  muscular  action  that  can 
not  be  thus  explained.  It  is  })Ossible,  of  course,  for  frac- 
ture to  occur  in  healthy  persons  in  consequence  of  antago- 
nistic action  on  the  part  of  the  abdominal  muscles  during 
the  lifting  of  heavy  weights.  My  own  observations  in- 
clude several  instances  of  this  nature. 

One  cavse  concerned  a  workman,  sixty  years  of  af^e,  who,  immedi- 
ately after  trying  to  catch  a  paving-stone  that  was  thrown  to  him,  felt 


196  DISEASES   CAUSED  BY  ACCIDENTS. 


PLATE  11. 

Case  of  Direct  Fracture  of  the  Eighth,  Ninth,  and  Tenth 
Right  Ribs  near  the  Vertebral  Column,  and  of  Indirect  Frac= 
ture  of  the  Seventh  and  Eighth  Ribs,  or  of  Their  Cartilages, 
in  the  Mammillary  Line,  Complicated  by  Fracture  of  the 
Body  of  the  Ninth  or  Tenth  Vertebra.  Sequel,  recover}^  with 
subsequent  severe  functional  disturbances  and  intercostal  neuralgia 
(referred  to  under  Fracture  of  the  Vertebraj). 

A  mason,  thirty-five  years  of  age,  on  October  5,  1895,  fell  from 
a  wall  aljout  twenty  feet  high,  sustaining  the  injuries  cited  above.  I 
examined  him  December  2>^,  1895,  and,  in  addition  to  the  symptoms 
due  to  the  spinal  lesion,  the  following  were  noted  :  The  seventh  rib 
on  the  right  side  protruded  sharply  in  the  mammillary  line;  over  the 
lower  part  of  the  left  lung  up  to  about  the  nipple  there  were  dullness 
and  diminished  respiratory  sounds;  e\en  light  percussion  was  very 
painful ;  the  least  touch  over  the  region  l)etween  the  eighth,  ninth,  and 
tenth  ribs  caused  the  patient  to  start  h-M-k  violently.  Posteriorly  along 
the  spine  there  was  sensitiveness  to  pressure  from  the  eighth  to  the 
tenth  ribs  inclusive.  This  sensitiveness  could  be  followed  in  the  inter- 
costal spates  to  the  front  of  the  chest  (intercostal  neuralgia).  The 
mobility  of  the  right  arm  at  the  shoulder-joint  was  restricted.  Insur- 
ance allowance,  100%. 


a  violent  stabbing  pain  in  the  left  side  of  his  chest.     A  diagnosis  was 
made  of  fracture  of  the  left  fifth  rib  near  the  anterior  axillary  line. 

Healing  is,  as  a  rule,  marked  by  only  a  slight  growth 
of  callus,  although  in  some  cases  a  relatively  large  forma- 
tion can  be  observ^ed.  I  have  seen  callus-tumors  of  the 
size  of  a  walnut,  or  even  considerably  larger  when  situated 
near  the  cartilage. 

In  an  average  case  of  fracture  of  the  ribs  in  a  full- 
grown  man  union  by  callus  takes  place  within  three  or 
four  weeks ;  the  process  may,  however,  be  completed 
earlier,  or  it  may  require  a  much  longer  time. 

The  ribs  usually  remain  in  position  after  fracture,  but 
may  be  considerably  displaced.  Sometimes  we  find  two 
adjacent  ribs  connected  by  a  bridge  of  callus.  When 
fracture  occurs  in  the  neighborhood  of  the  spine,  the  pos- 
terior vertebral  fragment  is  apt  to  be  displaced  behind  the 
anterior.  In  fractures  involving  the  sternal  ends  of  the 
ribs  the  reverse  holds  good.     Vertical  displacement  of 


Tab.  II. 


i 


LUh.  Atist  F.  ReidilKiUi .  Munclun. 


FRACTURES  OF   THE  RIBS.  197 

the  fragments  is  also  seen  in  some  cases.  The  injuries  of 
the  soft  parts — such  as  the  periosteum,  pleura,  and  mus- 
cles— are  followed  by  cicatricial  growth  leading  to  adhe- 
sions and  to  subsequent  contraction  of  the  tissues  involved. 
Aneurysms  occasionally  develop  as  a  result  of  laceration 
of  the  intercostal  arteries,  while  lacerations  or  other  injury 
of  the  intercostal  nerves,  although  causing  a  great  deal  of 
pain  at  first,  may  heal  perfectly  and  without  secpiels. 
The  result  is  not  always  so  favorable,  however,  the  dis- 
turbances sometimes  persisting  for  a  long  time,  or  even 
permanently. 

Symptoms  of  healed  fractures  of  the  ribs  depend  on  the 
form  of  the  lesion  (whether  direct  or  indirect),  the  struc- 
ture of  the  ribs,  the  age  of  the  individual,  the  manner 
and  duration  of  healing,  and  the  location  of  the  injury. 
Certain  sym])toms,  however,  are  common  to  all  cases. 

General  Symptoms. — In  all  cases  in  which  the  frac- 
ture involves  a  numl)er  of  adjacent  ribs,  symptoms  that 
continue  to  incommode  the  patient  for  a  long  time  are  met 
with  on  deep  inspiration  and  on  movement  of  the  trunk. 
He  finds  stooping  difficult,  as  also  the  lifting  of  weights, 
especially  with  the  arm  of  the  injured  side.  Pain  is 
caused  by  flexion  toward  the  opposite  side  and  by  deep  in- 
spiration. The  mobility  of  the  thorax  is  even  more  seri- 
ously affected  if  bony  union  takes  place  between  two  or 
more  adjacent  ribs  ;  in  these  cases  the  patient  is  unable  to 
raise  his  arm  easily  or  to  place  it  behind  his  back. 

The  prognosis  as  to  function  largely  depends  on  whether 
the  fracture  is  due  to  direct  or  to  indirect  violence.  In 
the  former  case  the  outlook  is  usually  less  favorable, 
because  of  the  danger  of  penetration  of  the  periosteum, 
])leura,  and  lungs,  or  other  organs,  by  the  sharp  fragments 
of  bone. 

Local  Symptoms. — Fractures  in  the  neighborhood  of 
the  spine  aft'ect  the  action  of  the  costotransverse  and  costo- 
vertebral articulations,  thereby  limiting  the  mol^ility  of 
the  spine  and  causing  })ain  on  movement.      Lacerations 


198  DISEASES  CAUSED  BY  ACCIDENTS. 

of  the  capsule  and  of  the  ligaments  of  these  joints  usually 
accompany  the  injury.  The  interarticular  ligament,  thin 
and  delicate  as  it  is,  which  binds  the  head  of  the  rib  to 
the  intervertebral  discs  of  two  adjacent  vertebrae,  is  doubt- 
less very  frequently  ruptured  in  these  cases,  and  the  pain 
felt  in  the  back  is  pr()l)ably  due  in  part  to  this  caus(\ 
Lesions  of  tlie  sympathetic  nerve,  with  their  attendant 
train  of  symptoms,  are  regularly  observed  when  the  frac- 
tured bones  are  forced  inward,  as  occurs  in  cases  of  direct 
fracture  due  to  falls  on  the  back,  blows  from  falling 
objects,  etc.,  or  when  the  rib  is  fractured  in  connection 
with  a  similar  injury  of  the  body  of  the  corresponding 
vertebra. 

The  clavicle  is  likely  to  be  loosened  from  its  attach- 
ment to  the  first  rib,  in  cases  of  fracture  of  the  latter,  in 
consequence  of  laceration  of  the  subclavius  muscle  or  of  the 
costoclavicular  ligament.  The  same  injury  leads  to  com- 
pression of  the  subclavian  artery,  and  thereby  to  disturb- 
ances of  circulation  and  nutrition  of  the  arm  that  it  sup- 
plies. The  mammary  artery  is  likewise  exposed  to  injury 
from  fracture  of  the  costal  cartilages. 

Direct  fractures  of  certain  ribs  are  likely  to  injure 
special  organs  and  structures.  Thus,  in  fracture  of  the 
sixth  rib  anteriorly  on  either  side  the  pleural  siiuis  is 
endangered ;  fracture  of  the  sternal  end  of  the  fourth, 
fifth,  and  sixth  ribs  on  the  left  side  imperils  the  peri- 
cardium and  branches  of  the  pneumogastric  nerve ;  in 
fracture  of  the  seventh,  eighth,  and  ninth  ribs  on  the 
right  side,  the  liver  ;  and,  in  case  of  the  ninth,  possibly 
also  the  gall-bladder.  In  fractures  of  the  ninth  to  the 
eleventh  ribs  inclusive,  on  the  left  side,  and  of  the  twelftli 
on  either  side,  the  spleen  and  kidneys,  respectively,  are 
liable  to  involvement.  The  stomach  may  be  injured  by 
forcible  compression  of  the  seventh,  eighth,  and  ninth 
ribs,  and  the  intestine  may  suffer  when  the  tenth  rib  is 
pressed  inward  or  fractured  l)y  direct  violence. 

The  following  descriptive  cases  illustrate  the  fact  that 


Fig.  26. 


200  DISEASES   CAUSED  BY  ACCIDENTS. 

the  symptoms  of  healed  fmetures  of  the  ril)s  depend 
largely  on  the  seat  of  the  lesion  ;  it  will,  therefore,  be 
unnecessary  to  state  the  various  local  symptoms  in  detail. 
It  is  iujportant  to  note  that  fractures  of  the  ribs  can 
easily  l)e  overlooked.  This  is  partly  due  to  the  fact  that 
some  individuals  are  rather  insensitive  to  pain,  and  do 
not  call  attention  to  the  lesion  by  their  comj^laints  ;  partly 
to  the  sinndtaneons  occurrence  of  other  and  more  serious 
injuries,  which  overshadow  the  one  in  (piestion. 

Ca.it'  of  fractnrc  of  llic  cii/IifJi,  iiiiilli,  oinl  fiiit/i  I'ilis  on  the  rii/lif  side, 
foUowed  by  intercoHfol  luurahjid  (iiul  rvstiiction  of  iiiohi/ity  of  tliv  lujlit 
shoulder.      (Fi<^.  2(3.) 

A  workman,  forty-four  years  of  age,  on  June  13,  189"*,  fell  and 
struck  the  riglit  side  of  his  chest  against  the  edge  of  a  wall.  The 
injury  left  a  slight  callous  tliickening  of  the  eighth  and  ninth  ril)8  in 
the  scapular  line.  There  was  consi(lcra))le  sensitiveness  to  ))ressure  in 
the  eighth  intercostal  space  on  the  right  side,  and  the  patient  was 
unable  to  lift  his  arm  well.  The  skiagraph  shows  the  point  of  frac- 
ture of  the  eighth  rilj,  l)etween  the  scapula  and  the  spine.  The  pa- 
tient was  dismissed  from  treatment  on  October  26,  189S,  with  an 
allowance  of  20%  insurance. 

Cdse  of  direct  fractiat'  of  the  ninth  ril)  on  the  right  side,  fottoired  hij  a 
diaphrdf/inatic  hernia. 

A  workman,  lifty-se\en  years  of  age,  on  .Tuly  f),  1H95,  fell,  striking 
the  right  side  of  his  chest  against  a  l)ox  of  lime.  He  is  s.iid  to  h.ave 
remainrd  unconscious  for  three  days  in  the  h()S])ital. 

I  examined  liim  on  Se])teml)er  2'^,  189.").  In  the  neighborliood  of 
the  ninth  ril)  on  the  right  side,  and  attached  to  it  in  the  axillary  line, 
there  was  a  marked  callous  thickening  ;  dullness,  pleuritic  friction- 
sounds,  i)leuritic  cough,  and  dyspnea  were  also  noted.  Beneath  the 
ensiform  cartilage  there  was  a  tumor  about  the  size  of  a  pigeon's  egg, 
which  protruded  on  coughing  and  could  l)e  pushed  back  into  the  ab- 
dominal cavity.  The  i)atient  was  unable  to  raise  the  right  arm  well 
or  to  do  any  lifting,     bisurance  allowance,  66|%. 

Cme  of  fraetiire  of  the  r//w  on  the  riyht  side  eoinplie(ded  hij  injury  of 
the  liver.     Sc((ui'l,  ])artial  recovery. 

A  polisher  by  trade,  fifty-seven  years  of  agi',  on  October  29,  1805, 
fell  from  a  scaffolding  about  ten  feet  high,  sticking  on  his  back, 
while  the  ))oards  of  the  scaffolding  fell  ujion  his  right  side.  He  was 
treated  at  home  for  eleven  days  and  then  uudcrlook  light  duties  as  an 
inspector. 

I  examined  him  February  26,  1S9(J,  and  found  a  slight  amount  of 
callus  on  the  seventh  right  rib  in  the  anterior  axillary  line;  also  pleu- 
I'itic  friction-sounds,  ])leuritic  cough,  and  marked  liypertroi)hy  and 
tenderness  of  the  liver.  It  was  dillicnlt  for  the  i)atient  to  raise  the 
right  arm  on  account  of  pain  in  the  shoulder  of  that  side.     He  has 


DISLOCATION  OF  THE  RIBS.  201 

not  worked  since  the  last  of  June  of  tliat  year.  I  last  examined  him 
on  Auf!:ust  15,  1896.  Tlie  liver  was  further  increased  in  size  and  was 
ver^'  sensitive  to  pressure. 

Case  of  fracture  of  a  number  of  ribs  due  to  severe  crushing,  complicated 
by  an  unusual  form  of  fracture  of  the  clavicle. 

A  painter,  fifty-four  yeai"s  of  age,  was  crushed  between  a  w^all 
and  a  heavy  truck,  sustaining  a  fracture  of  the  right  clavicle  at  its 
acromial  end  and  a  crushing  of  the  thorax.  He  was  treated  in  the 
hospital  for  fourteen  days  and  then  began  a  course  of  massage.  The 
fracture  of  tlie  ri))s  was  not  diagnosed. 

I  examined  the  patient  on  June  18,  1896,  and  he  remained  under 
my  care  until  April  of  the  following  year.  Skiagraphs  showed  a  frac- 
ture of  the  fifth,  sixth,  seventh,  eighth,  and  ninth  ribs  close  to  the 
spine,  in  addition  to  the  fracture  of  the  clavicle.  The  pain  that  he 
had  felt  in  the  spine,  especially  on  stooping,  was  hereby  explained. 
He  did  not  suffer  from  ijain  in  the  chest  after  December,  1896. 


FRACTURE  OF  THE  COSTAL  CARTILAGES. 

This  lesion  may  be  due  to  eitlier  direct  or  indirect  vio- 
lence. In  old  a_o'e,  when  the  cartilages  have,  as  a  rule, 
undergone  ossification,  it  is,  of  course,  incorrect  to  speak 
of  a  fracture  of  the  costal  cartilages. 

Fracture  of  the  cartilages,  or  of  the  ribs  in  their  imme- 
diate neighl)orhood,  is  not  infrequently  followed  by  an  ex- 
cessive growth  of  callus — in  reality,  an  exostosis.  The 
symptoms  of  the  lesion  do  not  differ  from  those  mentioned 
in  connection  with  fracture  of  the  ribs. 

The  treatment  of  healed  fractures  of  the  ribs  is  symp- 
tomatic. Mechanical  treatment  is  to  be  recommended  for 
limited  thoracic  mobility,  while  massage  and  electricity  of 
various  kinds  may  also  be  employed  with  advantage. 


DISLOCATION  OF  THE  RIBS. 

Dislocations  involving  the  costovertebral  and  the  chon- 
drosternal  articulations,  and  those  involving  the  two  lowest 
ribs,  are  usually  considered  separately.  Dislocations  at 
the  costotransverse  articulations  are  properly  included  with 
the  costovertebral  variety,  since  we  are  justified  in  assum- 
ing that  either   one  of  these  lesions  leads  to   the  other. 


202  DISEASES   CAUSED  BY  ACCIDENTS. 

Dislocations  of  the  ribs  at  tlieir  spinal  attaclinient  are  usu- 
ally met  with  as  aeconipanimeuts  of  fractures  of  the  ver- 
tebra, and  cau  usually  be  recognized  in  severe  eases  by 
local  pain,  especially  marked  on  attempting  to  move  the 
trunk,  by  symptoms  of  intercostal  neuritis,  and  by  disturb- 
ances due  to  lesions  of  the  sympathetic  nerve.  The 
symptoms  in  the  lighter  cases  are  only  slightly  marked, 
and  the  ])ain  in  the  spine  may  disappear  altogether  in  the 
course  of  a  few  months,  even  in  cases  of  dislocation-frac- 
tures involving  several  ribs. 

Dislocations  at  the  chondrosternal  articulations  are  not 
infrequently  seen  in  workmen  who  labor  in  a  stooping  po- 
sition or  in  those  who  have  occasion  to  lift  heavy  weights. 
Frequently,  the  lesion  is  really  a  subluxation,  which  can 
easily  be  reduced  by  ap})ro])riate  movements  of  retro- 
flexion. Dislocation  of  the  tirst  rib  also  calls  for  special 
mention.  The  lesion,  which,  by  reason  of  the  peculiar 
conformation  and  location  of  this  rib,  belongs  to  the  class 
of  dislocations  by  rotation,  occurs  at  the  chondrosternal 
articulation,  and  is  caused  l)y  fracture  of  the  rib  or  by 
violent  contusion  of  the  clavicle.  The  external  border  of 
the  I'ib  is  forced  downward,  causing  both  ends  to  rotate 
inward  and  upward.  The  remote  symptoms  of  the  iniury 
consist  of  pain  in  both  sternal  and  vertebral  articulations, 
especially  in  the  latter,  pain  in  the  neck,  and  limited 
mobility  of  the  head  and  neck, 

THE  SEQUELS  OF  FRACTURE  OF  THE  RIBS. 

I.  Intercostal  Neuralgia. 

The  consequences  of  the  lesion  in  question  have  in  large 
part  already  been  referred  to  in  connection  with  its  .sympto- 
matology ;  we  will  confine  ourselves  here  to  mentioning  a 
few  of  the  after-diseases  most  frequently  observed.  Inter- 
costal neuralgia  is  very  often  induced  by  direct  irritation 
from  displaced  fragments,  or  by  ])ressure  from  a  growing 
callus  or  from  adhesions  following  lesions  of  the  pleura. 


TRAUMATIC  PLEURISY.  203 

The  characteristic  symptoms  are  pain  and  extreme  sensi- 
tiveness in  the  course  of  the  affected  nerve.  Sensitive- 
ness can  be  elicited  by  pressure,  not  only  at  the  three 
points  usually  tested  for  diagnosis,  but  also  at  any  part  of 
the  course  of  the  nerve,  especially  at  the  points  at  which  it 
is  subjected  to  the  greatest  irritation.  Other  symptoms  are 
limited  ability  to  raise  the  arm  on  tlie  affected  side,  and  in 
many  cases  exaggerated  abdominal  reflexes,  increased  irri- 
tability to  the  faradic  or  franklinic  current,  and  dilatation 
of  the  ])U[)il  on  the  affected  side. 

Traumatic  intercostal  neuralgia  may  soon  disappear  or 
may  persist  for  a  long  time,  according  to  the  circumstances 
of  the  case;  and  upon  this  point  depends,  to  a  large  ex- 
tent, the  capacity  of  the  patient  for  self-support.  The 
average  incapacity  equals  20^,  but  rises  in  some  cases  as 
high  as  50^  or  more,  in  proportion  to  the  severity  of  the 
symptoms. 

Treat'ment  consists  of  warm,  moist  compresses,  massage 
along  the  course  of  the  nerve,  systematic  breathing-exer- 
cises, and  movements  of  the  trunk,  the  application  of  the 
galvanic  current,  gradually  increasing  its  intensity,  and  the 
use  of  the  static  machine. 

2.  Traumatic  Pleurisy. 

Traumatic  pleurisy  is  usually  of  the  fibrous  variety,  and 
may  deveh)p  in  consequence  of  direct  penetration  of  the 
pleura  by  fragments  of  bone,  or  as  a  result  of  incomplete 
fractures  of  the  ribs,  of  greater  or  less  extent,  due  to 
crushing  of  the  thorax  between  car-buffers,  under  wheels, 
under  falling  walls,  etc.  Pleurisy  has  even  been  known 
to  follow  blows  on  the  chest.  The  symptoms  are  dullness, 
pleuritic  friction-sounds,  and  the  cough  characteristic  of 
pleuritic  irritation,  always  ])resent  in  severe  cases.  In 
addition,  there  is  pain  on  deep  inspiration,  on  lying  on  the 
affected  side,  on  stooping,  and  on  lifting  the  arm  or  weights. 
The  expansion  of  the  affected  side  of  the  chest  is  dimin- 
ished.    For  the  early  treatment  of  these  cases  warm,  moist 


204  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  12. 

Case  of  Contusion  of  the  Left  Side  of  the  Thorax  due  to 
a  Fall  into  a  Cellar. 

Sequels,  thickened  pleura  and  tuberculosis,  resulting  in  complete 
incapacity  for  self-support. 

A  mason,  fifty-three  years  of  age,  fell  into  a  cellar  on  No^'ember 
28,  1895,  sustaining  a  fracture  of  the  os  calcis  of  botli  feet  and  a  con- 
tusion on  the  left  side  of  the  chest.  He  was  treated  in  the  hospital  for 
eight  weeks,  during  seven  of  which  he  remained  in  bed.  I  examined 
him  on  Fel)ruary  14,  IK^G,  and  found  him  to  be  a  man  of  middle  size, 
of  very  delicate  physiijue,  and  of  tubercular  diathesis.  There  was  a 
marked  depression  of  the  left  side  of  the  chest  from  the  fifth  rib  down- 
ward. (See  illustration. )  Tlie  depressed  area  was  very  sensitive  on 
percussion.  Circumscribed  dullness,  diminished  respiratory  sounds, 
jtleuritic  friction-sounds,  and  diminished  expansion  of  the  left  side  of 
the  chest  were  also  noted.  On  stooping,  the  lower  border  of  the  left 
ribs  became  very  prominent.  Lateral  movements  of  the  thorax  were 
limited,  especially  movement  toward  the  right.  The  patient  was  dis- 
charged after  four  months'  treatment  with  an  allowance  of  100%,  based 
on  his  pulmonary  tuberculosis. 

compresses,  rest  (in  bed,  if  necessary),  and  small  doses  of 
morpliin  are  to  be  recommended. 

Less  severe  cases  may  manifest  few  or  no  symptoms. 
Patients  frequently  resume  hard  work  after  a  course  of 
treatment  of  from  ten  to  twelve  days'  duration.  In  a 
stone-carrier,  for  instance,  whom  I  had  occasion  to  examine, 
and  who,  as  usual,  was  engaoed  in  hard  lal)or,  I  found  ex- 
treme dullness  and  ])leuritic  friction-sounds.  The  capacity 
for  self-support  varies,  it  is  thus  seen,  with  the  personal 
equation  of  the  patient. 

The  presence  of  ])lcuritic  symj)toms  in  an  otherwise  per- 
fectlv  healthy  individual  should  entitle  him  to  an  insurance 
allowance  of  20^;  severe  symptoms  may  call  for  a  higher 
allowance,  even  100  fo- 

The  pleurisy  may  clear  up  comparatively  soon  or  may 
persist  for  a  long  time  or  even  permanently;  not  infre- 
quently it  is  the  starting-point  for  the  future  development 
of  tuberculosis. 

The  ])leuritic  inflammation  occasionally  takes  a  serous 
or  suppurative  form,  requiring  a  prolonged  course  of  treat- 


Tab.    12. 


LUh.Arist  E  Reichhald  Miinrhpn 


INJURIES  OF  THE  LUNGS.  205 

ment.  One  workman,  who  developed  an  empyema  after 
fracture  of  a  rib,  was  under  treatment  for  three  years 
before  the  fistula  finally  closed  and  the  fever  disappeared. 
Contusions  of  the  thoracic  wall  and  healed  fractures  of 
the  ribs  are  not  infrequently  made  use  of  for  purposes  of 
simulation.  On  hasty  examination  a  constant  cough  in- 
duced in  the  larynx  or  jiharynx  may  be  mistaken  for  the 
cough  of  pleurisy,  and  an  incorrect  diagnosis  of  traumatic 
pleurisy  may  be  made  accordingly. 

Case  of  empyema  on  the  left  side  following  crushing  of  the  left  thigh, 
with  subsequent  ceHulifis  and  contusion  of  the  left  side  of  the  thorax,  com- 
plicated hfi  concussion  of  the  brain.  Sequels,  tliickened  pleui'a  and  a 
deep  cicatrix  at  the  site  of  the  fistula.  Four  years  later,  complete 
recovery  of  capacity  for  self-su])port. 

A  workman,  thirty-two  years  of  age,  fell  from  a  scaffolding  two 
stories  high  on  December  :29,  1893,  sustaining  the  injuries  men- 
tioned. There  were  no  thoracic  symptoms  at  tii-st.  Four  \\eeks  later, 
after  the  appearance  of  a  cellulitis  of  the  left  thigh,  pleurisy  set  in, 
with  cliills  and  high  fever.  Improvement  followed  incision  and 
drainage. 

I  examined  the  patient  on  A^iril  17,  1894,  and  found  a  fistula,  still 
discharging  pus,  between  the  seventh  and  eighth  riljs  on  the  left  side. 
There  was  dullness  over  the  \\hole  left  side  of  the  chest.  The  general 
health  was  good  as  long  as  drainage  remained  free;  symptoms  of  fever 
and  chills  were  manifested  whenever  the  listula  closed,  Ijut  ^vel■e  always 
relieved  by  reopening  the  same.  The  treatment  was  continued  until 
January,  1897,  when  the  patient  was  discharged  with  an  insurance 
allowance  of  75  % .  He  began  to  work,  and  ^vas  tinally  able  to  perform 
his  duties  so  well  that  his  allowance  was  diminisiied  to  10 /ir. 

3.  Injuries  and  Traumatic  Diseases  of  the    Lungs. — Hemop= 
tysis,  Pneumonia,  and  Pulmonary  Emphysema. 

The  lung-tissue  is  lacerated  in  case  of  direct  fracture 
of  the  ribs ;  also  in  case  of  violent  contusions  of  the 
thorax  due  to  falls  from  a  heig-ht  and  to  similar  accidents. 
The  immediate  symptoms  are  cough  and  bloody  sputum, 
and  these  may  be  followed  by  those  of  inflammation  of 
the  lungs. 

Pneumonia  is  observed  also  after  less  severe  contusions 
of  the  thorax  (contusion-pneumonia) ;  the  course  of  the 
disease  is  marked  by  only  a  slight  rise  of  temperature,  so 
that  the  patient  frequently  attempts  to  resume  work,  but 


206  DISEASES  CAUSED  BY  ACCIDENTS. 

is  soon  obliged  to  discontinue  it  again.  In  ])assing  we 
need  refer  only  to  the  pneumonia  induced  by  catching  cold, 
which  in  some  cases  also  entitles  the  patient  to  insurance 
allowance. 

Pulmonary  em])hysenui  is  frequently  of  traumatic  ori- 
gin, usually  developing  as  a  sequel  to  long-continued 
pleuritic  cough,  especially  in  individuals  suifering  from 
chronic  bronchitis. 

Hemoptysis  sometimes  occurs  in  consequence  of  strains 
— lifting  a  heavy  stone,  for  instance.  This  symptom  de- 
pends on  laceration  of  the  lung-tissue  and  its  capillaries, 
and  in  healthy  individuals  may  cause  no  further  trouble. 
Pulmonary  tuberculosis  is,  however,  very  apt  to  supervene 
in  those  who,  by  reason  of  their  occupation,  have  a  pre- 
disposition to  the  disease. 

Case  of  pneumonia  and  plenrisi/  consecutire  upon  falling  into  cold 
ivater.  Sequel,  myocarditis,  myelitis,  aucl  neurasthenia;  subsequent 
improvement. 

A  workman,  fifty-nine  years  of  age,  a  hea%'y  drinker,  fell  into 
the  water  on  January  18,  1894.  He  was  treated  in  the  hospital  for 
a  lono;  time,  and  was  then  discharged  improved,  only  to  be  read- 
mitted on  account  of  myf)carditis,  of  which  the  symptoms  had  mean- 
while increased.  The  following  symptoms  were  noted,  in  addition: 
loss  of  pupillary  reflex,  ataxic  gait,  swaying  of  body  on  closing  the 
eyes,  and  exagg-eration  of  the  patellar  reflexes.  Inca])acity  for  self- 
supjwrt,  lOO'^  ;  later,  when  the  symptoms  diminished,  50'^. 

A  c«.5f  of  hemoptysis  due  to  rupture  of  the  lunf/s  from  lifting  a  heavy 
stone.     Sequel,  pulmonary  tuljerculosis,  causing  deatli  in  two  years. 

A  stone-mason,  forty-ciight  years  of  age,  probably  already  tuber- 
cular, fell  in  attempting  to  lift  a  heavy  stone,  on  Aiigiist  22,  1889. 
The  accident  was  immediately  followed  by  hemoptysis. 

I  examined  him  three  months  later  and  found  a  cavity  in  the  right 
lung  Ijelow  the  clavicle;  also  a  few  rale;,  at  the  left  apex.  Insurance, 
which  Avas  at  first  denied  on  the  ground  that  the  accident  Avas  not  one 
covered  by  the  rules  of  his  trades-union,  was  afterward  allowed  him 
at  the  rate  of  100%.  He  died  two  years  later  of  pulmonary  tuljercu- 
losis. 

Case  of  hemoptysis  following  the  lifting  of  a  heavy  beam.  Sequel,  com- 
plete recovery. 

A  workman,  thirty-seven  years  of  age,  in  lifting  a  heavy  beam, 
on  July  10,  1894,  felt  a  sudden  violent  pain  and  jar  in  the  right  side 
of  the  chest.  Hemoptysis  followed.  He  was  treated  at  home  for 
eight  weeks.  I  examinetl  him  three  months  after  the  injury  and 
found  a  fibrous  pleurisy  of  moderate  intensity  on  the  right  side.     As 


TRAUMATIC  FULMONABY  TUBERCULOSIS.  207 

he  was  able  to  do  full  work,  he  was  not  considered  to  l)e  entitled  to 
insurance. 

Case  of  JicmopiijsiK  due  to  laceration  of  hni(f-1muc  in  conneetion  ivith 
fracture  of  the  ribs  following  a  fall  from  a  hcujht  of  sixty  feet.  Sequel, 
emphysema  of  the  lungs. 

A  mason,  thirty-live  year's  of  age,  fell  from  a  scaffolding  sixty 
feet  high,  on  November  Ifi,  1888,  sustaining  a  fracture  of  the  skull, 
laceration  of  the  lung,  and  a  fracture  of  the  right  arm;  also  a  fracture 
of  the  ribs  on  the  right  sidi',  wliich  was  not  diagnosed  until  later.  He 
was  treated  in  the  hosjjital  for  thirteen  weeks  and  then  entered 
my  care,  in  which  he  remained  for  one  year.  Symptoms,  loud  rales 
over  the  whole  of  the  right  lung,  bloody  sputum,  and  marked  loss  of 
flesh.  The  symptoms  gradually  decreavSed  in  the  course  of  time.  At 
present  he  is  still  suffering  from  emphysema.  He  was  allowed  100%, 
based  on  headac^he,  attacks  of  vertigo,  and  limited  mobility  at  the 
right  shoiilder. 

Case  of  hemoptysh  followinf)  a  trifling  injurij.  The  influence  of  the 
accident  was  recognized. 

A  Avorkman,  thirty-flve  years  of  age,  already  tubercular,  on  Janu- 
ary 8,  ISUG,  stepped  from  the  sidewalk  into  the  street  in  order  to  de- 
cipher the  number  of  a  house.  He  states  that  this  action  was  im- 
mediately followed  by  pain  in  the  back.  Ten  days  later  he  had  a 
hemorrhage  from  the  lung,  and  was  treated  in  the  hospital  for  a  week. 
He  had  previously  suffered  from  attacks  of  hemoptysis.  Insurance 
was  denied  him  by  his  trades-union  because  of  the  tuberculosis;  he 
was  declared  to  be  entitled  to  it,  however,  by  the  court  whose  opinion 
w^as  based  on  the  detiuled  and  unprejudiced  certificate  of  the  physi- 
cian who  examined  him. 


4.  Traumatic  Tuberculosis  of  the  Lung. 

It  is  undoubtedly  iu  rare  cases  only  that  tuberculosis 
develops  as  a  direct  result  of  traumatism.  As  a  rule, 
tuberculous  foci  are  already  present  and  are  called  into 
activity  by  the  injury,  or  the  development  of  the  disease 
is  only  hastened  by  the  latter.  The  exciting  traumatism 
does  not  necessarily  involve  the  region  of  the  tuberculous 
focus  ;  the  injured  part  may  recover  rapidly  and  com- 
pletely, while  the  tubercular  process  is  aroused  at  a  dis- 
tant spot. 

The  tuberculosis  may  l)e  latent  or  in  the  early  stages  of 
its  development,  giving  rise  to  scarcely  any  symptoms,  until 
active  symptoms  are  induced  by  traumatism  or  by  long 
confinement  in  an  unwholesome  dwelling  infected  witli 
tubercle  bacilli. 


208  DISEASES  CAUSED  BY  ACCIDENTS. 

Pulmonary  tuberculosis  may,  however,  develop  in  close 
connection  with  traumatism  as  a  sequel  to  a  traumatic 
hemorrhage,  which  furnishes  a  suitable  soil  for  the  growth 
of  the  invading  bacilli. 

The  tubercular  process  may  manifest  itself  as  a  primary 
local  lesion  after  injury  to  the  lung  or  pleura,  or  it  may  be 
established  in  some  part  of  the  lung  as  a  result  of  metas- 
tasis from  a  tuberculous  focus  developed  after  traumatism 
in  some  other  part  of  the  body.  Pulmonary  tuberculosis 
usually  incapacitates  the  patient  for  work  to  a  very  con- 
siderable degree  ;  he  is  always  unable  to  perform  hard 
labor,  and  in  many  cases  can  not  undertake  even  the 
lightest  tasks. 


INJURIES  AND  TRAUMATIC   DISEASES  OF  THE   HEART 
AND  PERICARDIUM. 

I.  Traumatic  Pericarditis. 

Direct  lesions  of  the  pericardium  are  usually  due  to  its 
penetration  by  fractured  ribs,  but  may  be  caused  by  pres- 
sure from  ribs  forced  inward  by  sudden  violence.  Diims 
reports  cases  of  traumatic  pericarditis  in  soldiers  who  had 
been  injured  by  blows  from  bayonets,  by  kicks,  or  by  falling 
and  strikino'  the  left  side  of  the  chest  against  the  horns  of 
their  saddles  or  by  being  thrown  to  the  ground  from  horse- 
back. Thicm  has  published  a  fatal  case  of  traumatic 
pericarditis  and  pleurisy  due  to  severe  crushing  contusion. 
If  the  pericardium  is  already  diseased,  it  is,  of  course, 
much  more  liable  to  inflanunation  as  a  result  of  trauma- 
tism than  is  normal  tissue. 

The  pericardium  is  in  some  cases  involved  secondarily 
by  extension  from  a  traumatic  pleurisy. 

The  sym])toms  of  traumatic  pericarditis  may  be  severe 
from  tlie  onset  or  may  at  first  be  so  slightly  marked  as  to 
be  overlooked  until  they  suddenly  break  out  later  on. 
Two  cases  are  related  by  Diims,  both  occurring  in  soldiers 
who  had  been  in  service  until  shortly  before  their  deaths. 


INJURIES  OF  THE  HEART.  209 

The  autopsy  showed  the  two  layers  of  the  pericardium  to 
be  adherent  almost  throughout. 

Alcoholic  or  tuberculous  subjects  are  predisposed  to  peri- 
carditis. The  loud  crackling  friction-sounds,  not  neces- 
sarily associated  with  the  movements  of  the  heart,  that 
characterize  the  lesion  can  be  heard  also  in  the  late  stages 
of  the  disease.  Frequently  adhesions  take  place  between 
the  pericardium  and  the  heart-muscle,  causing  disturb- 
ances of  cardiac  action  and  atrophy  of  the  muscle.  As 
long  as  the  sym]itoms  persist  the  patient  is  almost  com- 
pletely incapacitated  for  work,  and  should  be  prohibited 
from  all  exertion  or,  at  any  rate,  from  all  Init  the  very 
lightest  tasks. 

Case  of  periatnlUis  followuif/  fradure  of  the  left  sixth  rib,  caused  by  a 
fall  from  a  heifjht. 

A  Avorkinan,  thirty  years  of  age,  fell,  on  December  20,  1893, 
from  a  height  of  sixteen  feet,  sustaining  a  fracture  of  the  sixth  rib  in 
the  left  mammillary  line.  He  was  treated  for  four  weeks  with  ice-bags 
in  the  hospital.  After  his  discharge  he  became  a  patient  at  the  dispen- 
sary, Avhere  the  following  symptoms  of  pericarditis  were  demonstrated  : 
Dyspnea;  a  very  small,  rajiid,  and  irregular  pulse;  friction-sounds  and 
increased  area  of  heart-dullness.  These  symptoms  disappeared  at  the 
end  of  three  months.  He  was  allowed  50%  insurance  on  the  ground 
of  neurasthen' 

2.  Injuries  of  the  Heart  Due  to  Concussion. 

Direct  cardiac  lesions  have  been  reported  as  occurring 
in  individuals  thrown  from  a  moving  train  (case  of  Liersch), 
or  in  those  who  have  fallen  from  the  upper  story  of  a 
house,  striking  on  the  buttocks  (case  of  Riedinger).  In 
the  case  described  by  Liersch  autopsy  showed  hemorrhages 
under  the  endocardium. 

Lacerations  of  the  heart-muscle,  also  of  the  papillary 
muscles,  valves,  and  chordae  tendinse,  have  been  found  in 
cases  of  crushing  of  the  thorax  between  car-buffers,  under 
falling  walls,  etc.,  or  as  a  result  of  kicks  from  animals 
(Stern  and  Bernstein). 

The  cardiac  muscle  or  the  valves  may  also  be  lacerated 
in  direct  consequence  of  strains — due  to  the  lifting  of 
14 


210  DISEASES  CAUSED  BY  ACCIDENTS. 

heavy  weights,  for  instance.  A  case  published  by  Schin- 
dler  was  that  of  a  very  strong  hod-carrier,  who  was  accus- 
tomed to  carrying  a  load  of  forty-two  bricks,  weighing 
165  kilos,  on  his  shoulder,  while  his  fellow-workmen 
were  able  to  carry  only  thirty-two,  weighing  120  kilos. 
In  attempting  to  carry  forty-eight  bricks  he  broke  down, 
and  became  ill.  One  year  later,  when  fully  recovered,  he 
again  attempted  the  same  extra  load,  with  the  same  result. 
A  diagnosis  was  made  of  acute  dilatation  of  the  left  ven- 
tricle, with  mitral  insufficiency  and  irregular  heart-action, 
leading  to  edema  and  ascites,  completely  disabling  the 
patient. 

According  to  Bernstein,  the  laceration  is  most  likely  to 
occur  in  that  part  of  the  cardiac  structure  that  is  in  a  state 
of  tension  at  the  moment  of  injury.  Thus,  during  sys- 
tole the  cardiac  muscle  suffers ;  during  the  second  half 
of  diastole,  when  the  nuiscle  is  relaxed,  the  endocar- 
dium ;  and  during  the  whole  diastole  of  the  ventricles,  the 
valves  that  lie  in  front  of  them.  Bernstein  states  that  the 
valvular  lesion  of  traumatism  is  characterized  by  a  rough 
murmur,  audible  at  a  considerable  distance,  differing  from 
the  murmur  of  gradual  development  heard  in  cases  of 
valvular  insufficiency  of  inflanmiatory  origin.  A  murmur 
audible  at  a  distance  of  over  fifty  centimeters  may,  he 
says,  be  assumed  to  have  a  traumatic  cause.  Lesions  of 
this  nature  have  been  observed  involving  the  mitral,  tri- 
cuspid, and  semilunar  valves. 

The  symptoms  of  traumatic  cardiac  lesions  are,  in  the 
main,  those  of  similar  lesions  of  nontraumatic  nature  ;  the 
patient  is  usually  greatly  incapacitated  for  work,  being 
able  to  perform  only  light  tasks  requiring  no  physical 
exertion,  if,  indeed,  he  is  able  to  work  at  all. 

3.  Influence  of  Traumatism  on  Preexisting  Heart  Disease. 

Hearts  that  are  already  the  seat  of  some  morbid  process 
are  necessarily  much  more  likely  to  siiffi'r  from  the  effects 
of  traumatism  than  are  previously  healthy  organs. 


TRAUMATIC   THORACIC  ANEURYSM.  211 

Stern  gives  the  following  causes  for  the  increase  of 
cardiac  symptoms  after  accidents  : 

1.  Mental  excitement. 

2.  General  concussion  and  direct  injuries,  such  as  con- 
tusions, crushings,  etc. 

3.  Muscular  exertion  or  strain. 

Thiem  adds  a  fourth  cause  :  namely,  sudden  cooling  of 
the  body. 

Cases  of  all  these  forms  of  injury  can  be  found  in 
abundance  in  the  literature. 

4.  Aneurysm  of  the  Thoracic  Aorta. 

A  case  of  this  lesion  is  published  by  Pauli  in  which  the 
patient,  a  coachman,  fifty-three  years  of  age,  was  struck 
on  the  left  side  of  the  chest  by  a  moving  railroad-car.  He 
suffered  at  first  from  extreme  dyspnea  ;  then,  after  a  short 
period  of  slight  improvement,  he  again  became  ill,  this 
time  with  severe  symptoms  of  palpitation  of  the  heart  as 
well  as  dyspnea.  The  area  of  heart-dullness  extended  to 
the  right  margin  of  the  sternum,  while  the  whole  region 
pulsated  strongly.  The  heart-sounds  remained  normal. 
The  accident  occurred  on  March  3,  1894  ;  in  October  of 
the  same  year  it  was  noticed  that  the  second  and  third 
left  ribs  were  beginning  to  protrude.  The  patient  died 
suddenly  on  August  28,  1895.  Antopsy  showed  an 
aneurysm  about  ten  centimeters  long  ;  the  heart  was  greatly 
hypertrophied,  especially  the  left  ventricle  ;  the  first  part 
of  the  aorta  was  much  dilated,  preventing  closure  of  the 
semilunar  valve. 

Case  of  mitral  insufficiency  followint/  sererc  crushinf/  of  the  left  side  of 
the  chest.     Sequel,  partial  recovery. 

A  mason,  thirty-two  years  of  a.sje,  on  September  16,  1892,  was? 
caught  iinder  a  falling  building.  He  sustained  the  foregoing  injury, 
and,  in  addition,  a  severe  contusion  of  the  right  hip.  He  w;us  treated 
at  home  for  three  months,  with  compresses  and  rest  in  bed,  and  then 
came  under  my  care.  He  showed  symptoms  of  sciatica  on  the  right 
side,  and  complained,  in  addition,  of  frecpient  attacks  of  dyspnea. 
Examination  was  negati\e,  except  that  there  was  a  rapid  pvilse.  The 
heart-symptoms  increased  a  few  weeks  later,  and  were  accompanied  by 


212  DISEASES  CAUSED  BY  ACCIDENTS. 

fever.  He  was  again  ordered  to  remain  in  bed.  Tiie  phy.sician  in 
attendance  at  his  home  made  a  diagnosis  of  endocarditis,  ^^^len  I 
examined  him  snbsetinently,  I  found  tne  apex-ljeat  disphxced  to  the 
left,  a  blowing  systolic  murmur,  and  the  area  of  heart-dullness  en- 
larged toward  both  sides.  Insm'ance  allowance,  50^.  No  change  in 
his  condition  \\\}  to  date. 


IV.  INJURIES  AND  TRAUMATIC  DISEASES  OF 
THE  ABDOMEN. 

Although  the  abdominal  organs  are  not  protected  from 
external  violence  by  a  bony  framework,  a.s  are  the  brain, 
the  spinal  cord,  and  the  thora(;ic  organs,  they  are  never- 
theless well  adapted  to  evade  the  effects  of  traumatism. 
This  is  especially  true  of  the  stomach  and  intestines  ;  less 
so  of  the  glandular  organs — the  liver,  kidneys,  and  spleen; 
the  latter,  however,  by  reason  of  their  position  in  the  body, 
are  less  exposed  to  external  injury.  The  ability  of  the 
stomach  and  intestine  to  escape  injury  by  moving  to  one 
side  has,  of  course,  its  limits,  and  when  filled  with  gas  or 
food-contents,  they  are  not  easily  dis})laced,  and  are, 
therefore,  in  much  greater  danger  from  traumatism. 

The  lesions  of  the  internal  organs  do  not  always  cor- 
respond in  situation  to  the  point  to  which  the  external 
violence  is  applied  ;  if  kicked  by  a  horse,  for  instance,  on 
the  lower  left  part  of  the  thoracic  wall,  the  individual 
may  suffer  comparatively  little  damage  at  that  point, 
while  the  intestine  is  ruptured  at  a  distance. 


I.  INJURIES  OF  THE  ABDOMINAL  WALL. 
(a)  Wounds  and  Cicatrices  of  the  Abdominal  Wall. 

Superficial  wounds  in  this  situation,  including  those 
caused  by  burns,  usually  heal  well,  and  without  sequels 
of  im])ortance.  Extensive  scars,  however,  especially  if 
showing  a  tendency  to  keloid  formation,  are  likely  to  give 
rise   to    a   feeling  of  tension  and   pressure.     The  symp- 


INJURIES  OF  THE  ST03IACff.  213 

toms  of  scars  left  1)y  deep  wounds  are  more  marked  and 
vary  in  intensity  in  projxtrtion  to  the  depth  of  the  scar- 
tissue  and  to  the  adhesions  it  forms.  The  broad  scars 
that  sometimes  follow  perforating  abdominal  wounds  lead 
to  the  development  of  omental  hernia,  and,  finally,  to 
hernia  of  the  intestines. 

(b)  Subcutaneous  Rupture  of  Abdominal  Muscles. 

This  lesion  occurs  in  consequence  of  violent  contraction 
when  the  muscle  is  in  a  state  of  extreme  tension,  as  in 
lifting  and  carrying  heavy  weights  Avith  the  hands,  the 
trunk  being  inclined  backward.  Subcutaneous  ruptures 
are  also  met  with  when  the  l)ody  is  in  a  position  of  exten- 
sion, as,  for  instance,  in  hanging  from  horizontal  bars.  The 
rectus  is  most  subject  to  the  injury,  the  external  oblique 
somewhat  less  so.  I  have  seen  a  rupture  of  the  external 
oblique  in  a  recruit  undergoing  fatiguing  practice  on  hori- 
zontal bars,  and  a  rupture  of  the  same  muscle  in  a  woman 
about  forty-five  years  of  age  as  a  result  of  strain  in  lifting. 
The  muscles  heal  in  from  three  to  six  weeks,  usually  leav- 
ing a  depression  or  groove  at  the  point  of  rupture.  Hard 
labor,  lifting,  and  carrying  heavy  loads  are,  of  course,  out 
of  the  question  at  first ;  but  as  strength  gradually  returns, 
even  such  work  can  once  more  be  undertaken.  Incapacity 
for  self-support,  20  ^  to  33^  ^ . 


2.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
STOMACH. 

(a)  Contusions  and  Crushing  of  the  Stomach. 

When  empty,  the  stomach  usually  escapes  the  effects 
of  a  blow  or  kick  by  moving  aside  ;  but  it  may  suf- 
fer serious  lesions,  as  a  result  of  compression  against  the 
vertebral  c(jlunin,  in  cases  of  crushing  between  car-buf- 
fers, under  falling  walls,  wheels  of  wagons,  etc.  The 
lesion  may  consist  of  lacerations  of  the  nmcous  membrane, 


214  DISEASES  CAUSED  BY  ACCIDENTS. 

of  hemorrhage  between  diiferent  layers  of  the  stomach- 
wall,  or  even  of  rupture  of  the  latter,  doniantling  imme- 
diate operation.  When  the  organ  is  full,  the  mucous 
membrane  is  sometimes  torn  as  the  result  of  comparatively 
slight  injuries,  such  as  simple  contusions  or  muscular 
strain  in  lifting,  or  concussiim  due  to  falls  from  a  height. 
As  a  rule,  the  stomach,  in  these  cases,  is  already  the  seat 
of  some  morbid  process.  Rupture  of  the  gastric  mucous 
membrane  is  immediately  followed  by  hematemesis  or 
bloody  passages  from  the  bowels.  In  cases  of  gastric 
ulcer  due  to  infection  of  the  injured  mucous  membrane 
through  the  stomach-contents  hematemesis  may  occur  as  a 
somewhat  later  symptom. 

Case  of  conhmon  of  ihe  chest  and  stomach  due  to  a  blow  from,  a  wagon- 
pole.  Sequels,  chronic  gastritis,  thickened  pleura,  and  pulmonary 
emphysema. 

A  workman,  sixty-four  years  of  age,  on  October  13,  1892,  was 
struck  on  the  lower  anterior  Ijorder  of  the  ril)S  on  the  left  side  by  a 
wagon-pole.  He  at  once  became  unconscious,  and  was  carried  home, 
where  he  was  treated  for  traumatic  pleurisy. 

I  examined  him  on  January  20,  1893,  and  found  \m\\  to  be  a  small, 
delicate  man,  who,  however,  stated  that  he  never  was  seriously  ill 
before  his  accident,  having  suffered  only  from  paralysis  of  the  vocal 
cords.  The  ])atient  complained  of  attacks  of  nausea,  poor  appetite, 
and  a  feeling  of  pressure  in  the  stomach;  his  tongue  was  coated. 
Further  examination  showed  a  thickening  of  the  left  pleura  and  some 
emphysema  of  the  lungs  ;  also  tenderness  on  pressm'e  in  the  region  of 
the  stomach.     Insurance  allowance,  75%. 

(b)  Traumatic  Ulcer  of  the  Stomach. 

These  ulcers  usually  heal  rapidly,  but  in  some  cases 
lead  to  perforation.  It  is  hardly  necessary  to  state  that 
perforation  may  take  place  at  the  site  of  a  nontraumatic; 
ulcer  in  cases  of  traumatism,  thereby  entitling  the  patient 
to  receive  insurance.  The  cicatrix  left  after  healing  is 
completed  causes  no  after-trouble  in  favorable  cases,  but 
occasionally  proves  to  be  the  starting-point  of  a  carci- 
nomatous growth. 

Weak,  anemic  individuals,  particularly  alcoholics,  are 
predisposed  to  gastric  ulcer. 


CANCER  OF  THE  STOMACH.  215 

The  patient  should  be  ordered  rest,  possibly  in  bed. 
The  insurance  allowance  may  equal  100^. 

(c)  Carcinoma  of  the  Stomach. 

Reference  has  just  been  made  to  the  origin  of  carcino- 
mata  at  the  site  of  gastric  ulcers.  Carcinoma  seldom 
occurs  in  consequence  of  a  single  traumatic  insult,  but 
is  usually  the  outcome  of  constant  irritation  of  the  scar- 
tissue.  If  the  mucous  membrane  is  already  unhealthy, 
however,  it  is  also  possible  for  a  carcinoma  to  develop 
after  a  single  injury.  The  underlying  cause  may,  for 
instance,  be  a  chronic  gastritis ;  the  immediate  cause,  a 
traumatism  that  produces  a  laceration  of  the  nnicous 
membrane,  leading  successively  to  a  gastric  ulcer,  a  cica- 
trix, and  finally  to  the  development  of  a  carcinoma.  The 
cases  of  traumatic  carcinoma  that  have  come  under  my 
observation  occurred  in  individuals  between  forty-five  and 
fifty-five  years  of  age,  all  of  whom  suffered  from  chronic 
gastritis  due  to  alcoliolism. 

The  etiologic  connection  between  traumatism  and  carci- 
noma must  be  clearly  proved  on  scientific  grounds  ;  it  will 
not  do,  for  instance,  to  try  to  connect  an  inflammation  of 
the  elbow-joint  or  a  wound  of  the  head  with  a  primary 
carcinoma  of  the  digestive  tract  of  subsequent  develop- 
ment. In  respect  to  this  point,  see  also  the  opinions  of 
Schonborn,  Senator,  and  Renvers,  published  in  the  official 
reports  of  the  State  Insurance  Bureau. 

Case  of  carcinoma  of  the  stomach  the  development  of  which  was  hastened 
by  an  accident.     Fatal  termination. 

A  carpenter,  fifty  years  of  age,  fell  from  a  height  of  aljout  two 
stories  on  July  9,  1898,  sustaining  a  fracture  of  the  right  scapula  com- 
plicated by  concussion  of  the  brain.  He  was  treated  for  a  month  or 
more  in  the  hospital.  I  examined  him  on  Noveniljer  2,  1898,  and 
found  liiin  to  be  a  ratlier  large,  thin  man  of  sickly  appearance.  The 
spine  of  the  right  scapula  was  distinctly  thickened,  and  the  right  arm 
could  not  be  raised  al)o\e  a  level  with  the  shoulder.  He  was  treated 
clinically  )jy  means  of  exercises  of  the  right  shoulder.  On  December 
29,  1H98,  he  did  not  appear  at  the  clinic,  and  was,  therefore,  visited  at 
his  home.  He  was  found  to  be  suffering  from  gastric  disturbances, 
but  had  no  fever.     He  stated  that  he  had  noticed  a  loss  of  appetite 


216  DISEASES  CA USED  ST  A CCIDENTS. 

and  rapid  loss  of  strength  ever  since  his  accident,  and  that  he  was  previ- 
ously (juite  liealthy.  He  confessed  to  having  drunk  a  moderate  amount 
of  whisky  daily  and  to  having  eaten  irregularly.  Hematemesis 
occurred  on  January  18,  1899,  when  he  was  taken  to  the  hospital  on 
account  of  a  tumor  of  the  stomach.  He  died  there  soon  after^\ard. 
Autopsy  showed  a  carcinoma  of  the  stomach.  The  traumatic  etiology 
was  admitted. 

(d)  Nervous  Dyspepsia. 

Reference  is  here  made  to  this  utfection  for  the  reason 
that  we  often  meet  with  it  as  a  symptom  of  accident-neu- 
rosis, and  that  it  very  frequently  calls  for  treatment.  In 
addition  to  other  treatment,  psychic  methods  are  to  be 
recommended. 


3.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE  INTES= 
TINE  AND  THE  PERITONEUM. 

(a)  Contusions  and  Crushing  of  the  Intestine. 

The  intestine,  like  the  stomach,  is  likely  to  escape 
injury  from  external  violence,  such  as  falls,  blows,  or 
kicks,  when  it  is  empty.  If,  however,  it  is  the  seat  of 
typhoid  ulcers  (in  cases  of  walking  typhoid)  or  of  tuber- 
cular ulcers,  rupture  of  the  mucous  membrane,  or  even 
])erforation  of  the  intestinal  wall,  may  easily  occur. 
The  intestine  may  be  ruptured  in  healthy  persons  by 
crushing  of  the  al)domen,  due  to  being  run  over,  caught 
under  falling  buildings,  etc.  This  lesion  is  more  likely  to 
occur  when  the  intestines  are  filled.  The  most  frequent 
traumatic  causes  of  intestinal  rupture  are  kicks  and  vio- 
lent concussion  consequent  upon  falls  from  a  height. 
Rupture  may  occur  at  the  time,  or  gangrene  may  set  in  at 
the  point  of  injury,  leading  to  perforation  several  days 
later.  In  other  cases  the  lesion  in  the  mucous  membrane 
is  in  the  process  of  healing,  when  peristalsis  or  some 
movement  on  the  part  of  the  patient  causes  the  weak  spot 
to  give  way,  and  a  perforation  results. 

If  the  accident  does  not  cause  immediate  death,  the 
patient's  life  may  be  saved  by  operative  interference.     An 


TRAUMATIC  PERITONITIS.  217 

instance  of  this  kind,  including  a  description  of  the  sequels, 
will  be  found  among  the  illustrative  cases. 

Minute  openings  in  the  intestine,  several  millimeters  in 
length,  may  heal  without  difficulty  ;  even  if  there  is  an 
escape  of  intestinal  contents,  these  openings  may  become 
encapsulated  and  recovery  may  take  place.  Internal 
ruptures  are,  therefore,  not  necessarily  fatal  accidents. 

(b)  Wounds  of  the  Intestine. 

These  occur  in  cases  of  fracture  of  the  ribs,  vertebrae, 
or  pelvis,  the  sharp  fragments  piercing  the  intestine  ;  or 
they  are  produced  from  within  by  the  action  of  foreign 
bodies  that  have  been  swallowed.  The  only  hope  of  re- 
covery lies,  as  a  rule,  in  immediate  operation. 

(c)  Intestinal  Stenosis  and  Occlusion. 

Stenosis  of  the  intestine,  up  to  complete  occlusion,  may 
occur  as  a  result  of  traumatism.  Among  the  direct  causes 
are  foreign  bodies  in  the  intestine,  cicatricial  strictures, 
and  incarcerated  hernias.  The  first  aim  of  treatment 
should,  of  course,  be  the  removal  of  the  cause. 

(d)  Traumatic  Peritonitis. 

Lesions  of  the  peritoneum  are  invariably  accompanied 
by  more  or  less  extensive  lacerations  of  the  omentum  and 
of  the  vessels  that  it  contains.  The  injury  and  the  sub- 
sequent hemorrhage  are  follo^ved  by  a  peritonitis,  as  a 
result  of  which  the  extra vasated  blood  may  become  en- 
capsulated, forming  a  hematocele.  The  peritonitis  in  it- 
self is  rarely  of  a  very  serious  nature. 

Hermes  mentions  the  case  of  a  man  who  fell  on  a  beam 
from  a  height  of  one  story,  striking  upon  the  abdomen, 
thereby  causing  a  complete  laceration  of  the  omentum 
between  its  middle  and  lower  thirds  and  almost  entirely 
separating  the  small  intestine  from  its  mesentery.  Thiem 
describes  an  interestins:  case  of  incarceration  of  a  coil  of 


218  DISEASES   CAUSED   BY  ACCIDENTS. 

small  intestine  in  a  tear  in  the  mesentery,  occurring  in  a 
man  who  had  k'a})ed  across  a  ditch  with  the  aid  of  a  pole. 

The  peritonitis  may  assume  a  suppurative  character  in 
consequence  of  the  passage  of  infectious  bacteria  either 
through  the  uninjured  intestinal  wall  or  out  of  the  blood- 
vessels in  which  they  may  be  circulating. 

Traumatic  peritonitis  often  leads  to  the  formation  of 
adhesions  with  neighboring  organs ;  these  are  likely  later 
on  to  give  rise  to  rather  severe,  ill-defined  pains,  often 
ascribed  to  hysteria  or  to  simulation,  or  set  down  as  "  colic." 

Carcinoma  of  the  peritoneum  is  usually  of  metastatic 
origin,  the  primary  focus  being  seated  in  the  stomach, 
liver,  or  rectum,  etc. 

Case  of  perityphlitis  following  severe  crushing  of  Ihe  abdomen.  Se- 
quel, recovery,  with  persistence  of  various  syinptoins. 

A  Avorkman,  thirty-three  years  of  age,  was  injured  in  November, 
1887,  by  a  rail  falling  on  the  right  side  of  his  abdomen.  He  was 
treated  in  the  hospital  for  a  number  of  weeks,  and  soon  after  his  dis- 
charge was  readmitted  on  account  of  a  psoas  abscess.  I  examined 
him  on  October  27,  1888.  I  found  Iiim  to  be  a  man  of  middle  size  and 
vigorous  build  and  of  rather  pale  complexion.  He  complained  of  ab- 
dominal pain,  of  severe  constipation,  sometimes  lasting  for  eight  days 
or  longer,  and  of  a  sense  of  weight  in  the  right  leg.  At  the  lower  part 
of  the  abdomen  on  the  right  side  was  situated  a  flat  tumor,  about  the 
size  of  tlie  palm  of  the  hand,  slightly  raised  aliove  the  level  of  the  sur- 
rounding tissue.  The  whole  right  side  of  the  abdomen  was  sensitive 
to  pressure  and  the  right  lower  extremity  was  swollen,  the  circumfer- 
ence of  the  thigh  being  three  centimeters  greater  than  that  of  the  left. 
He  was  at  first  allowed  full  insurance,  which  was  reduced  in  six  months 
to  50%,  and  in  two  years  to  20%.  At  the  time  of  the  last  examina- 
tion, early  in  the  year  1899,  the  tumor  in  the  right  side  of  the 
abdomen  had  disappeared  and  the  swelling  of  tlie  right  thigh  had 
diminLshed. 

(e)  Laceration  of  the  Thoracic  Duct. 

In  his  "  Manual "  Thiem  cites  a  case  observed  by  Man- 
ley  concerning  a  man  thirty-five  years  of  age  who  was 
knocked  down  by  a  wagon-pole,  which  struck  him  in  the 
abdomen,  one  wheel  passing  over  his  body.  The  injury 
was  followed  by  severe  pain ;  a  tumor  developed  over 
Poupart's  ligament  on  the  right  side,  which  Avas  tapped 
eleven  days  later,  yielding  a  pint  of  a  milky-white  fluid. 


INJURIES  OF  THE  LIVER.  219 


4.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE  LIVER. 

Lesions  of  this  organ  may  be  clue  to  tlirect  or  indirect 
violence.  Contusion  and  crushing  of  the  liver  belong  to 
the  class  of  direct  injuries,  and  are  met  with  in  individuals 
who  have  received  blows  from  butts  of  guns,  horns  of 
animals,  or  Avagon-poles,  or  who  have  been  struck  Avith 
the  fist  or  kicked  bv  horses,  cattle,  etc.  They  also  occur 
in  persons  who  have  fallen  on  the  abdomen,  or  Avho  have 
been  caught  under  heavy  falling  objects,  under  falling 
buildings,  under  wheels,  between  parts  of  machinery,  car- 
buffers,  etc.  Lesions  of  the  liver  due  to  direct  violence 
are  not  infrequently  seen  in  connection  with  complete  or 
incomjjlete  fractures  of  the  ril>s. 

Indirect  lesions  are  caused  by  falls  from  a  height,  strik- 
ing on  the  feet,  the  buttocks,  the  back,  or  the  left  side  of 
the  abdomen. 

If  diseased,  the  liver  may  be  ruptured  by  a  slight  degree 
of  violence,  as  when  it  is  the  seat  of  a  hydatid  cyst ;  the 
consequences  of  injury,  too,  both  immediate  and  remote, 
are  likely  to  be  more  serious  than  in  the  case  of  a  healthy 
organ. 

The  symptoms  of  injuries  of  the  liver  depend  on  its  phy- 
siologic condition  and  on  the  severity  of  the  lesion  ;  slight 
hemorrhages  or  small  tears  of  the  surface  are  followed  by 
very  mild  symptoms,  or  cause  only  moderate  pain.  Rest 
and  suitable  treatment  bring  about  recoveiy  in  these  cases. 

Ruptures  of  the  liver,  on  the  other  hand,  often  termi- 
nate fatally  very  shortly  after  the  accident ;  the  lesion  is 
in  many  cases  marked  by  characteristic  pain  in  the  right 
shoulder.  Patients  who  survive  the  injury  suffer  from 
jaundice,  localized  peritonitis,  or,  less  frequently,  from 
abscess  of  the  liver,  which,  as  it  is  well  to  remember,  may 
remain  latent  for  years. 

In  healing,  adhesions  are  formed  between  the  surface 
of  the  liver  and  its  peritoneal  coat,  causing  pain,  especially 
on  movements  requiring  considerable  exertion,  on  unusual 


220  DISEASES   CAUSED  BY  ACCIDENTS. 

degrees  of  peristalsis,  or  when  the  stomach  and  intestines 
are  full  and  heavy. 

In  view  of  the  inaljility  of  the  patient  to  perform  hard 
work,  he  may  be  entitled  to  an  insurance  allowance  of 
from  33 J ^  to  66|^,  or  more. 

Carcinoma  of  the  liver  is  usually  a  secondary  process, 
the  result  of  metastasis  from  a  primary  growth  in  the 
stomach,  rectum,  esophagus,  or  intestine  ;  in  rare  cases  we 
find  a  primary  carcinoma  of  the  bile-ducts. 


5.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
SPLEEN. 

Direct  contusion  and  crushing  of  the  spleen  may  occur 
in  connection  with  crushing  and  fracture  of  the  ninth  to 
eleventh  ribs,  leading  to  hemorrhage  and  laceration,  and 
to  loosening  of  its  ligamentous  attachments,  and  to  subse- 
quent iuflannnation  of  tiie  organ  and  its  coats.  Occasion- 
ally, a  wandering  spleen  is  observed  after  traumatism.  As 
a  result  of  inflammation,  adhesions  take  place  between  the 
spleen  and  adjacent  organs.  Chronic  hypertrophy  and 
leukemia  have  likewise  been  observed.  In  cases  of 
malaria  or  leukemia  the  spleen  is  occasionally  ruptured  by 
trivial  accidents. 


6.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
PANCREAS. 

Hemorrhagic;  and  sup])urative  pancreatitis  and  necrosis 
of  parts  or  the  Avhole  of  the  organ  have  been  known  to 
occur  as  the  result  of  a  fall  or  of  being  run  over.  Cysts 
of  traumatic  origin  have  lieen  observed  in  a  number  of 
cases,  giving  rise  to  the  following  symptoms  :  a  grayish- 
yellow  coloration  of  the  skin,  similar  to  that  seen  in 
Addison's  disease  ;  gastric  disturbances,  vomiting,  and 
neuralgia. 


INJURIES  OF  THE  KIDNEY.  221 


7.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
KIDNEY. 

The  kidneys  may  be  injured  by  direct  or  indirect  vio- 
lence. They  are  most  exposed  to  direct  injury  from 
behind,  below  the  eleventh  or  twelfth  rib,  but  may  also 
be  reached  anteriorly  or  from  the  side.  Fracture  of  the 
eleventh  or  twelfth  rib  may  cause  a  direct  lesion  of  the 
kidney,  while  in  case  of  fracture  of  the  eleventh  or  twelfth 
dorsal  vertebra,  or  of  the  first  or  second  lumbar  vertebra, 
the  lesion  may  be  either  direct  or  indirect. 

Contusion  and  crushing  of  the  kidney  occur  in  conse- 
quence of  kicks,  or  blows  from  sticks,  wagon-poles,  etc. ; 
also  in  individuals  who  are  run  over  or  caught  under 
falling  walls,  etc.  If  diseased,  the  kidney  may  be  indi- 
rectly injured  l)y  falls  on  the  buttocks  or  by  muscular 
contraction — the  lifting  of  heavy  weights,  for  instance. 

The  lesion  produced  by  the  various  forms  of  traumat- 
ism mentioned  usually  takes  the  shape  of  a  laceration, 
accompanied  h\  more  or  less  severe  hemorrhage  and 
followed  by  hematuria,  which  is  the  most  striking  symptom 
produced.  It  may  a})pear  at  once  or  may  be  delayed 
until  the  clots  that  temporarily  fill  the  laceration  become 
detached.  In  some  cases  hematuria  does  not  appear  ;  the 
blood  collects  between  the  layers  of  the  capsule,  giving 
rise  to  inflammation  (traumatic  nej)hritis),  or  forming  a 
cyst,  or  leading  to  the  development  of  a  perinephritic 
abscess,  accompanied  by  the  formation  of  calculi  and  the 
atrophy  of  the  kidney.  Injuries  to  the  kidney  are  occa- 
sionally followed  l)y  anuria,  either  of  reflex  origin  or  due 
to  the  fact  that  the  second  kidney  is  diseased  or  lacking. 
Albuminuria,  causing  edema  of  one  or  both  legs,  frequently 
involving  the  side  opposite  to  the  injured  kidney,  is 
another  syni])toni  of  traumatic  nephritis. 

Lacerations  of  the  kidney  are  not  necessarily  accom- 
panied by  severe  symptoms ;  the  latter  may  be  quite 
trivial,  causing  no  discomfort  after  the  first  few  days. 


222  DISEASES  CAUSED  BY  ACCIDENTS. 

Floating  kidney  is  frequently  met  with,  especially  in 
women,  and  may  depend  on  one  of  several  cases  :  dimin- 
ution in  the  normal  amount  of  adipose  tissue  surrounding 
the  kidney,  relaxation  of  the  abdominal  walls,  a  tumor 
of  the  kidney  or  neighboring  structures,  or  traumatism. 
Thiem  agrees  with  Cruveilhier  in  explaining  the  trau- 
matic origin  of  floating  kidney  by  the  narrowing  of  the 
niche  or  groove  in  which  the  kidney  rests,  which  takes 
place  as  the  result  of  external  violence  or  depends  on  in- 
ternal causes.  Blows  from  behind  and  from  the  side  or 
falls  on  the  abdomen  or  against  shar])-edged  objects 
have  the  effect  of  forcing  the  lower  ril)s  toward  the 
spine,  thereby  narrowing  the  kidney  groove.  Muscular 
contraction  may  act  similarly  on  the  ribs,  as  when, 
after  slipping,  a  person  tries  to  regain  his  equilibrium,  and 
in  so  doing  involuntarily  contracts  certain  nuiscles — the 
quadratus  lumborum,  the  erector  spina?,  and  the  abdominal 
muscles.  Continuous  attacks  of  coughing  also  reduce  the 
size  of  the  groove  C(mtaining  the  kidney,  which  explains 
the  appearance  of  floating  kidney  subsequent  to  heavy 
lifting  or  to  other  work  requiring  severe  exertion  during 
which  a  prolonged  attack  of  coughing  occurred.  The 
condition  is  further  favored  by  lordosis  of  the  spine, 
which  itself  may  be  of  traumatic  origin. 

The  symptoms  of  floating  kidney  are  of  a  kind  usually 
regarded  as  hysteric.  Tiiey  consist  of  anesthesia  and  hy- 
peresthesia of  the  mucous  membrane  of  the  bladder  ;  ]>ain 
in  the  lower  part  of  the  back  and  in  the  loins  ;  disturb- 
ances of  digestion,  which  may  be  due  to  ])ressure  of  the 
displaced  kidney  on  the  duodenum  ;  and  jaundice  caused 
by  pressure  or  tension  on  the  common  bile-duct.  If  the 
pedicle  becomes  twisted,  there  may,  in  addition,  be  urin- 
ary disturbances,  albuminuria  and  fever,  and  even  hydro- 
ne])hrosis. 

The  symptoms  can  be  relieved  by  a  suitable  abdominal 
bandage  or  can  l)e  cured  l)y  surgical  interference,  with  the 
object  of  fixing  the  displaced  kidney  in  position. 


TRAUMATIC  HYDRONEPHROSIS.  223 

Traumatic  hydronephrosis,  in  addition  to  twisting 
of  tiie  kidney  pedicle,  may  be  due  to  occlusion  of  the 
ureter  from  the  following  causes  : 

1.  Traumatic  stricture. 

2.  Presence  of  a  coagulum. 

3.  Impaction  of  a  renal  calculus  loosened  from  the 
kidney  by  traumatism. 

4.  Compression  from  hemorrhagic  extravasation  or  by 
tumors  of  the  peritoneum  or  ureter. 

Perinephritis  sometimes  occurs  as  a  sequel  to  a  hemor- 
rhagic extravasation  at  the  point  of  injury,  which  subse- 
quently became  iufected.  The  abscess  either  points  below 
the  twelfth  rib  or  breaks  through  the  trigonum  of  Petit, 
or  it  descends  into  the  pelvis  or  inguinal  region,  to  appear- 
as  a  psoas  abscess. 

Penetrating  wounds  of  the  kidney  caused  by  pointed 
instruments  may  run  a  very  favorable  course  if  surgical 
aid  is  at  once  summoned.  In  one  case  of  my  own  (men- 
tioned among  the  illustrative  cases)  the  patient  was  able  to 
resume  regular  work  about  three  months  after  the  injury. 

The  rate  of  insurance  to  1)e  allowed  for  the  various 
injuries  of  the  kidney  and  their  sequels  depends  on  the 
severity  of  the  symptoms  in  the  later  stages  of  the  injury  ; 
these  may  be  so  slight  as  not  to  interfere  in  the  least  with 
work  or  they  may  incapacitate  the  patient  to  a  large 
degree. 

Carcinoma  of  the  kidney  occasionally  develops  after 
traumatism.  In  ^a  case  of  Lowenthal's  cited  by  Thiem, 
in  which  the  etiologic  relation  was  fully  established,  death 
occurred  seventeen  years  after  the  accident. 

The  insurance  allowance  for  the  loss  of  one  kidney  by 
operation  is  from  33|^^  to  50^. 

Cafie  of  floating  kidney  folloicing  contusion  of  the  Jmek  and  '^laceration 
of  the  kidnei/."  Sequel,  decided  improvement  and  complete  capacity 
for  self-support. 

A  mason,  twenty-seven  years  of  age,  on  August  30,  1893,  fell  and 
struck  tlie  right  side  of  his  back  against  a  jirojecting  screw  of  a  ma- 
chine.    Hematuria  is  said  to  have  occurred  immediately  afterward. 


224  DISEASES   CAUSED  BV  ACCIDENTS. 

Examination  a  few  weeks  later  .showed  a  floating  kidney  on  the  right 
side.  The  svniptonis  were  jjain  in  the  l)aek  and  aI)donien,  nausea,  and 
absence  of  kidnev-diillness  oi>  the  right  side.  On  Ooto))er  11,  1S94,  the 
floating  kidney  had  disappeared  ;  the  patient  was,  therefore,  declared 
capable  of  self-support. 

rw.sc  of  rupture  of  the  kidney  due  to  a  fcdl  from  a  scaffolding.  Seqnel, 
hydronephrosis  ;  subsequent  improvement. 

A  carpenter,  twenty-six  years  of  age,  fell  backward  from  a  scaffold- 
ing nine  feet  high  on  August  28,  1895.  He  sustained  a  contusion  of 
the  back  and  a  laceration  of  the  left  kidney,  for  which  he  entered  the 
hospital  for  treatment. 

I  examined  him  on  January  28,  1896.  He  was  a  small,  thick -set, 
pale-faced  man.  The  region  of  the  left  kidney  posteriori^'  wa>s  dis- 
tinctly swollen  ;  the  percussion-note  was  tympanitic  and  the  l>ounda- 
ries  of  kidney -dullness  were  extended  on  all  sides.  Albrmiin  was 
present  in  the  iirine.  The  patient  was  treated  in  the  dispensary  and 
hospital,  and  evinced  improvement  later  on.  Insurance  allowance, 
30%. 


8.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE  BLAD= 
DER,  URETERS,  TESTICLES,  AND  PENIS. 

Lesions  of  the  bladder,  including  rupture,  are  met 
with  as  the  resuU  of  direct  violence  in  individuals  who 
have  been  run  over,  caught  between  moving  objects,  under 
falling  walls,  etc.,  or  who  have  sustained  a  fracture  of  the 
])elvis,  the  organ  having  been  pierced  by  the  broken  bones. 
Indirectly,  the  bladder  may  be  injured  by  lifting  heavy 
weights.  It  is  much  more  liable  to  suifer  Avhen  full  than 
when  empty.  Immediate  operation  may  save  the  patient's 
life  and  may  lead  to  permanent  recovery. 

Lesions  of  the  bladder  may  be  followed  by  catarrhal 
inflammation,  calculus,  or  polyuria  ;  the  last-named  affec- 
tion is  especiallv  l)urdensome  to  a  working-man. 

Crushing  of  the  testicle  may  be  followed  by  hydro- 
cele, hematocele,  or  suppurative  orchitis.  If  a  hydro- 
cele is  already  present,  the  injury  is  likely  to  cause  con- 
siderable hemorrhage,  which  is  best  treated  by  operation, 
although  good  resnlts  may  also  be  obtain(>d  by  elevation 
of  the  thighs,  rest  in  bed,  and  the  application  of  com- 
presses. A  suspen.sory  bandage  should  subsecpiently  be 
worn  for  some  time. 


( 


INJURIES  OF  THE  TESTICLES. 


225 


Cutaneous  wounds  of  the  testicle,  if  properly  treated, 
heal  quickly  and  completely.      Unless  inflamed,  a   hydro- 
cele of  moderate  size  usually  causes  no  troulde  'whatever, 
and  its  presence  does  not  neces- 
sarily interfere  with  hard  work. 
In  estimating   the   insurance  we 
should,  therefore,  not  allow  high 
rates,  unless  signs  of  inflanmia- 
tion    are    found,    and   if   so,    we 
should  treat  the  condition. 

The  loss  of  one  testicle  is  of 
no  special  importance  so  long  as 
the  other  is  healthy.  The  loss 
of  both  testicles  not  only  destroys 
the  power  of  procreation,  but 
entails,  in  addition,  a  series  of 
nervous  symptoms.  An  allow- 
ance of  50^  is,  therefore,  fre- 
quently justitied. 

Tuberculosis  has  been  known 
to  develop  in  oneorliotii  testicles 
as  the  result  of  crushing.  For 
these  cases  castration  is  indi- 
cated. 

It  is  reasonable  to  believe 
that  carcinoma  of  the  testicles 
may  develop  in  consecpunce  of 
traumatism,  but  each  case  nmst 
be  carefully  examined  Avith  refer- 
ence to  its  etiology,  since  the 
disease  is  quite  frequently  ob- 
served when  no  history  of  injury 
is  given. 

The  strictures  of  the  urethra 
that  usually  form  after  traumatism   are 
difficult  micturition,  requirins 
fitting   the   patient    for  work. 
15 


Fig.  27. 

likely  to  cause 
treatment  and  partly  un- 
An    insurance    allowance 


226  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  13. 
Case  of  Acquired  Ventral  Hernia  Intensified  by  Traumatism. 

A  workman,  iifty-three  years  of  age,  in  trying  to  extricate  himself 
from  a  mass  of  earth  which  had  fallen  around  liim,  co\cring  him  iip  to 
his  knees,  felt  intense  pain  at  the  nmljilicus,  at  wliicli  point  there  had 
existed  a  small  hernia  for  a  long  time.  Tlie  hernia  is  stated  to  have 
greatly  increased  in  size  after  the  injiii-y,  and  at  the  time  of  my  exami- 
nation it  was  about  the  size  of  the  palm  ot  the  hand.  The  patient 
had  a  rather  prominent  abdomen.  He  complained  of  continual  pain 
in  the  abdomen,  and  stated  that  he  wa.s  unable  to  walk  \vithout  an 
abdominal  bandage.  He  also  suffered  from  i^eriosteitis  of  tlie  tibite. 
The  total  insurance  allowance  equaled  50^. 


of  from  25^    to    50^    is    frequently  justified   in    these 
cases. 

Wounds  and  contusions  of  the  penis  may  give  rise 
to  scars  and  deformities,  sometimes  involvino;  a  loss  of 
functional  power.  Urethral  strictures  also  occur  in  this 
connection.  The  same  rate  of  insurance  is  allowed  for 
loss  of  the  penis  as  for  the  loss  of  the  testicles. 

Case  of  severe  contusion  of  f/ic  abdomen  and  rupinrc  of  f/ie  bladder,  due 
to  ihe  kick  of  a  horse.     (Fig.  27.)    Followed  by  operation  and  recovery. 

A  driver,  twenty-two  years  of  age,  was  kicked  in  tlie  alidomen  by  a 
horse.  He  became  unconscious  and  was  taken  at  once  to  a  hospital 
and  there  operated  upon. 

I  examined  him  on  March  20,  1899.  He  was  of  medium  height  and 
vigorous  build.  The  scar  in  the  linea  alba  extended  almost  from  the 
umbilicus  to  the  symi^hysis  ;  it  was  of  recent  appearance  and  was  sen- 
sitive to  pressure,  as  was  also  the  abdomen.  The  patient  suffered  from 
polyuria  (he  was  o))liged  to  urinate  at  least  twenty  times  a  day)  and 
constipation.  The  left  lower  extremity  was  swollen  and  edematous, 
and  there  was  cyanosis  of  the  foot  and  of  the  lo\ver  part  of  the  leg 
(probably  due  to  pressure  on  the  left  external  or  common  iliac  vein). 
The  abdomen  and  tlie  left  leg  were  su])i)orted  by  bandages.  Full 
capacity  for  self-su])port  wiis  restored  in  about  four  months. 

Case  of  h'sio)i  of  the  bladder  and  urethra.  Operation  was  followed  by 
recovery  except  for  persistent  polyuria. 

A  painter,  thirty-five  years  of  age,  was  precipitated  from  a  sc^affold- 
ing,  the  latter  giving  way  on  April  25,  1890.  The  testicles  and 
urethra  were  injured  by  a  broken  board,  which  also  i)ierced  the  al)do- 
men,  causing  a  lesion  of  the  bladder.  An  operation  was  undertaken 
a  few  hours  later  in  the  hospital.  The  scar  left  by  the  incision  is  still 
very  apparent;  it  is  three  centimeters  wide,  rather  thick,  adherent, 
and  fixed.     It  is  also  sensitive  to  pressure.     The  patient  suffers  from 


7'(rb.  JJ. 


J.iUi.  Artst  F.  Re'CfituiUI.  Miiurhen,. 


HERNIA.  227 

persistent  polyuria.  His  allowance  was  at  first  estimated  at  45%  ;  for 
the  past  two  years  it  has  been  25  % . 

C'ase  of  scrcrc  coniiision.  of  the  urefhra  dttc  to  a  fall.  Followed  by 
stricture  and  albuminuria. 

A  workman,  twenty-five  years  of  age,  fell  into  a  trench  on  November 
28,  189:5,  sustaining  a  severe  contusion  of  tiie  urethra,  which  required 
operation.  Since  reco^•ery  he  has  suffered  from  stricture,  polyuria, 
and  frequent  attacks  of  albumiiuiria.     Insurance  allowance,  50/^. 


9.  HERNIA. 

Tlie  external  protrusion  of  any  part  of  tlie  intestine  out 
of  tlie  abdoniinal  cavity  or  its  escape  into  another  body- 
cavity  is  called  a  hernia.  The  existence  of  an  opening  in 
one  of  the  walls  bounding  the  abdominal  cavity  is  an  es- 
sential factor  in  the  occurrence  of  a  hernia.  The  opening 
in  the  muscular  or  fibrous  tissue  composing  the  abdominal 
wall  may  bo  congenital  or  acquired,  or  it  may  be  produced 
by  traimiatism.  Certain  natural  openings  exist  for  the 
passage  of  nerves  and  vessels,  and  for  the  passage  of  the 
spermatic  cord  in  males  and  of  the  round  ligament  in 
females.  These  openings,  however,  do  not  permit  the 
escape  of  the  intestines  unless  for  some  reason  they  be- 
come stretched  or  enlarged.  Subcutaneous  rupture  may 
occur  at  any  jjoint  of  the  abdominal  wall  as  a  residt  of 
traumatism,  and  it  is  with  the  hernias  that  originate  thus 
that  wc  are  here  concerned. 

Case  of  ventral  hernia  caufted  l)y  falling  from  a  scaffold  in  f/  and  sfrik- 
inff  on  the  abdomen.     Seqiiel,  traumatic  x»eritonitis. 

A  painter,  forty-four  years  of  age,  fell  from  a  scaffolding,  October 
2fi,  1890,  striking  on  the  abdomen  and  the  right  hand.  He  sustained 
a  fracture  of  the  right  radius  and  a  severe  contusion  of  the  abdomen, 
followed  l)y  peritonitis.  He  was  treated  in  the  hospital  for  si.K  weeks. 
Wliile  there,  a  diagnosis  was  made  of  hernia,  which  had  descended  in 
consequence  of  the  fall.  I  examined  the  patient  on  January  24,  1891. 
I  found  a  hernia  in  the  linea  alba,  about  a  hand's-width  below  the 
ensiform  cartilage.  It  was  aboiit  the  size  of  a  fist.  From  the  hernia 
one  could  trace  a  movable,  rather  thick  cord,  which  extended  ob- 
liquely across  to  the  lower  border  of  the  ribs  in  the  left  axillary  line. 
An  insurance  allowance  of  60%  was  made,  on  account  of  the  pain 
caused  by  stooping  and  because  of  the  inability  of  the  patient  to  lift 
anything  from  the  ground.  The  connection  jjetween  the  traumatism 
and  the  hernia  was  conceded. 


228  DISEASES   CAUSED  BY  ACCIDENTS. 

Cnse  of  traumntic  nmbilicol  hernia  due  to  muscular  strain. 

A  stone  polisher,  fifty-two  years  of  age,  stout,  on  September  15, 
11^91,  in  lifting  a  very  heavy  block  of  stone  felt  an  intense  cutting 
l)ain  in  the  region  of  the  umbilicus,  accomjianied  by  the  sensation  of 
something  having  been  forced  out  of  his  abdomen.  On  examining  the 
latter  he  discovered  a  soft  tumor,  the  size  of  a  cherry,  which  protruded 
again  every  time  it  was  pushed  back.  The  physician  whom  he  con- 
sulted diagnosed  an  umbilical  hernia.  The  insurance  allowance  was 
estimated  at  10 '/r.  By  the  12th  of  January,  189:^,  the  hernia  liad  in- 
creased to  the  size  of  an  apjjle.  Since  that  time  it  has  not  grown 
larger,  and  is  held  back  liy  an  abdominal  bandage.  The  patient  com- 
plains of  painful  defecation  and  obstinate  consti])ation,  and  of  vertigo 
on  stooping.  He  is  unable  to  lift,  even  moderate  weights,  and  is  occa- 
sionally obliged  to  interrupt  his  work  on  account  of  an  exacerbation 
of  the  symijtoms. 

Case  of  ventral  hernia  (hernia  linen?  albse)  tvith  operation  and  eonse- 
quent  transverse  diri.'<ion  between  the  muscles  of  the  abdominal  wall. 

A  workman,  sixty  years  of  age,  sustained  a  trivial  contusion-wound 
in  the  left  inguinal  fold  and  was  taken  to  a  hospital.  AVhile  there  he 
was  operated  upon  for  a  central  hernia  of  long  standing,  Avhich  occa- 
sioned respiratory  and  digestive  disturliances.  After  the  operation  his 
symptoms  increased,  and  he  demanded  compensation.  He  subse- 
quently received  an  allowance  of  30%  from  the  State  Insurance  Bu- 
leau.  On  coughing,  the  hernia  jirotruded  through  the  interval  between 
the  muscles. 

Traumatic  Inguinal  Hernia. 

Inguinal  hernia  is  very  frequently  seen  in  working-men. 
It  usually  occurs  as  a  single  lesion,  although  double  in- 
guinal hernia  may  also  be  met  with.  Among  the  large  num- 
ber of  acquired  inguinal  hernias  that  I  have  seen  in  an 
accident-practice  of  thirteen  years'  standing  I  have  met 
with  only  tliirty-one  cases  of  the  traumatic  form. 

By  the  term  inguinal  hernia  we  understand  the  hernial 
tumor  that,  entering  the  inguinal  canal  through  the  in- 
ternal abdominal  ring,  remaius  in  tlie  canal  in  the  form  of 
an  interstitial  hernia,  or  escapes  through  the  external  ab- 
dominal ring  to  the  surface  of  the  body,  either  appearing 
as  a  tumor  at  that  ]X)int  or  passing  down  into  the  scrotum 
to  become  a  scrotal  hernia. 

Inguinal  hernia  may  be  direct  or  indirect.  In  tiie 
indirect  form,  which  is  that  most  often  seen,  the  hernia 
follows  the  course  of  the  inguinal  canal, — or,  in  other 
words,  the  course  of  the  spermatic  cord, — either  remain- 


TRA  UMA  TIC  ING  UINA  L  HERNIA .  229 

ing  in  tlie  canal  as  an  interstitial  hernia  or  passing  ont  of 
the  external  abdominal  ring  to  descend  to  the  scrotum, 
there  to  form  a  scrotal  hernia. 

In  the  direct  form  the  hernia  forces  its  way  through 
part  of  the  thickness  of  the  abdominal  wall,  and  enters 
the  inguinal  canal  on  the  inner  side  of  the  epigastric 
artery,  passing  through  only  a  part  of  the  canal  on  its 
way  to  the  external  abdominal  ring.  Its  course,  therefore, 
is  from  behind  directly  forward. 

The  inguinal  canal  may  be  stretched  and  enlarged  by  a 
single  traumatism,  sometimes  in  consequence  of  a  tear  in 
the  inguinal  ring.  Its  enlargement,  however,  is  usually 
to  be  ascribed  to  atrophy  of  the  preperitoneal  fat,  occur- 
ring most  commonly  in  old  persons,  as  a  result  of  which 
the  natural  openings  in  the  abdominal  wall  appear 
stretched.  Folds  of  the  peritoneum  that  have  become 
relaxed  around  the  opening  are  forced  into  it  by  abdom- 
inal pressure,  and  if  the  intestine  follows  this  peritoneal 
sac,  the  development  of  the  hernia  is  complete. 

The  escape  of  the  intestine  into  the  opening  may  occur 
as  a  result  of  muscular  exertion,  such  as  heavy  lifting, 
or  simply  from  coughing  or  sneezing.  The  process  does 
not  necessarily  cause  pain  ;  on  the  contrary,  it  often  gives 
rise  to  no  symptoms  M'liatever  and  is  (juite  unknown  to 
the  patient.  This  is  the  rule  in  nontraumatic  cases.  Pain 
is  felt,  however,  in  cases  of  traumatic  hernia  when  the 
inguinal  ring-  is  suddenlv  stretched  or  torn,  or  when  the 
hernia  becomes  strangulated  ;  it  is  u]ion  these  conditions 
that  compensation  is  mainly  based.  We  shall  have  occa- 
sion to  refer  again  to  this  point.  Inguinal  hernia  may,  as 
already  stated,  occur  on  one  or  both  sides  ;  a  double  hernia, 
however,  is  rarely  of  traumatic  origin. 

A  hernia  niust  be  distinguished  from  a  protrusion  of 
the  abdominal  wall  in  the  region  of  the  inguinal  canal, ^ 
accompanied  by  pathologic  enlargement  of  the  external 
abdominal  ring,  which  is  seen  on  expiration,  and  which  is 
due  to  local  weakness  of  the  abdominal  wall.     This  con- 


230  DISEASES   CAUSED  BY  ACCIDENTS. 

stitutes  a  predisposition  to  liornia.  Kaufman n  defines  this 
predisposition  as  an  enlargement  oi"  the  external  abdominal 
ring,  the  inguinal  canal,  and  the  internal  alxlominal  ring, 
and  a  diminished  resistance  of  the  anterior  wall  of  the 
inguirial  canal. 

A  careful  differential  diagnosis  must  be  made  between 
a  predisposition  to  hernia  and  an  interstitial  hernia.  The 
latter  appears  in  the  course  of  the  inguinal  canal  as  a  flat- 
tened tumor  which  does  not  pass  through  the  external 
abdominal  ring.  This  form  of  hernia  usually  causes  the 
most  marked  symptoms  and  is  most  exposed  to  the  danger 
of  strangulation  at  the  internal  ring. 

An  inguinal  hernia  may,  as  regards  its  size,  be  as  small 
as  a  pigeon's  e^g,  or  it  may  form  an  immense  tumor  reach- 
ing down  to  the  knee.  The  chief  symjrtoms  are  local 
pain  and  general  abdominal  pain.  The  danger  of  stran- 
gulation is  always  present.  While  small  hernias,  especially 
of  the  interstitial  variety,  may  give  rise  to  considerable 
pain  and  discomfort,  large  scrotal  hernias  usually  cause  no 
trouble  whatever,  unless  they  are  so  large  as  to  be  painful 
by  reason  of  their  weight. 

Intense  pain  is  caused,  as  a  rule,  by  the  sudden  de\el- 
opment  of  an  inguinal  hernia  in  cases  of  traumatism. 
Very  often  we  find  swelling  and  inflammation  of  the  ab- 
dominal wall  at  a  jioint  corresponding  to  that  at  which  the 
hernia  esca|)ed  ;  if  this  diagnostic  sign  is  not  present,  it  is 
often  impossible  to  differentiate  between  a  recent  hernia 
and  one  of  long  standing.  We  can  not  always  judge  of 
the  age  of  a  hernia  by  its  size.  An  interstitial  hernia  the 
size  of  a  walnut  may  have  existed  for  years  ;  but,  on  the 
other  hand,  we  are  justified  in  assuming  that  a  large  scrotal 
hernia  is  not  of  recent  origin.  A  hernia  of  long  standing- 
is  indicated  by  thickening  of  the  sac  and  its  coverings  and 
by  a  large  opening. 

While  these  points  go  to  prove  the  age  of  a  hernia,  the 
fact  that  the  tumor  is  small  and  flattened  does  not  by  any 
means  signify  that  it  is  of  recent  development. 


HERNIA  AND  INSURANCE.  231 

Although  in  many  cases  a  licrnia,  even  if  of  large  size, 
may  exist  for  years  without  causing  any  pain  or  inconve- 
nience, the  individual  sometimes  remaining  ignorant  of  his 
condition,  the  suffering  that  is  experienced  in  other  cases 
justifies  the  declaration  of  Koenig  that  hernia  is  "a  wide- 
spread disorder,  limiting  the  working  capacity  of  mankind, 
and  frequently  leading  to  the  most  serious  consequences." 

Treatment  of  Inguinal  Hernia. 

If  after  a  hernia  is  properly  reduced,  it  can  be  held  in 
position  by  a  well-fitting  truss,  this  apparatus  affords  the 
patient  great  relief  and  reduces  the  danger  of  strangulation 
to  a  minimum.  \  radical  operation  is  to  be  advised,  how- 
ever, if  the  hernia  continues  to  be  troublesome  at  times 
in  spite  of  a  truss,  and  it  is  always  indicated  in  case  of 
irreducible  strangulated  hernia,  A  truss  or  a  suitable 
bandage  should  be  worn  after  operation,  even  if  this  is 
quite  successful,  as  the  hernia  may  otherwise  reappear  after 
a  time.  In  addition  to  keeping  the  truss  in  good  condi- 
tion, the  patient  should  see  that  his  bowels  act  regularly, 
and  should  avoid  alxlominal  strain  and  the  carrying  of 
heavy  weights. 

Compensation  for  Inguinal  Hernia. 

The  State  Insurance  Bureau  allows  insurance  for  an 
inguinal  hernia  of  long  standing,  the  descent  of  which  is 
due  to  traumatism,  as  well  as  for  a  recent  hernia  of  sud- 
den traumatic  development.  A  predisposition  to  inguinal 
hernia  does  not  constitute  a  claim  for  compensation. 

According  to  the  sense  of  the  Accident  Insurance  Law, 
the  essential  fact  in  determining  the  payment  of  indem- 
nity is  not  an  existing  tendency  to  inguinal  hernia,  but 
the  so-called  descent  of  the  hernia  :  /.  e.,  descent  of  a  por- 
tion of  the  intestine  through  the  hernial  opening  of  the 
inguinal  canal. 

The  descent  of  an  old  hernia  is  regarded  by  the  In- 
surance   Bureau    as   unfavorable   to   the   physical   condi- 


232  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  14. 

Cicatrix  Following  Operation  on  a  Case  of  Strangulated 
Inguinal  Hernia. 

A  stoneiiiason's  apprentice,  eigliteen  years  of  aj^e,  in  lifting  an  iron 
l)eani  produced  a  strangulation  of  the  right  inguinal  hernia  from  which 
lie  already  suti'ered.  He  was  operated  upon  in  the  hospitid.  After 
recovery  he  ccjuiplained  of  a  marked  feeling  of  tension  in  the  cicatrix 
and  of  pain  on  coughing  or  sneezing  or  on  attempting  to  lift  heavy 
weights.  He  at  first  recei\ed  \i)'^i  allowance,  A\hich  \\as  later  reduced 
to  20%.  Coughing  caused  the  scar  and  the  surrounding  tissues  to 
protrude.     The  patient  wears  a  truss. 


tion  of  tlie  affected  individual.  The  attitude  of  the  State 
Insurance  Bureau  is  justified  liy  tlie  fact  that  the  work- 
ing capacity  of  a  man  who  depends  for  his  living  on 
muscular  exertion  is  invariably  diminished  by  the  de- 
scent of  an  inguinal  hernia.  He  is  obliged  to  wear  a 
Avell-fitting  truss  and  to  see  that  it  constantly  retains  the 
hernia,  not  only  in  order  to  avoid  the  suffering  and  dis- 
comfort consequent  upon  the  descent  of  the  hernia,  but  also 
to  obviate  the  danger  of  possible  strangulation.  The  State 
Insurance  Bureau  also  takes  the  position  that  it  is  of  no  con- 
sequence whether  or  not  it  is  ])ossible  for  an  inguinal 
hernia  to  develoj)  suddenly  in  consequence  of  traumatism. 

The  conditions  under  which  the  existence  of  an  accident 
justifying  indenniity  are  recognized  are,  according  to 
Kaufmann,  the  following  — 

I.   Actual  accidents  ;  such  as  : 

1.  Direct  physical  violence  in  the  hernial  region. 

2.  Slipping  or  falling  when  lifting  or  handling  heavy 
weights. 

II.  Unusual  exertions;  for  exanqile  : 

1.  Work  that  must  be  done  under  unusually  unfavor- 
able conditions. 

2.  Exertion  to  which  the  workman  is  unaccustomed. 

3.  Exertion  exceeding  the  limits  of  ordinary  industrial 
labor  (umisual  exertion  in  respect  to  the  age  and  strength 
of  the  workman). 


Tab.   14. 


Lull . .  I ".-/  /  ■  llpithltMd.  Miinchen. 


HERNIA  AND  INSURANCE.  233 

< 

"  To  justify  the  payment  of  insurance  the  hernia  must 
be  deveh)ped  suddenly  and  be  accompanied  by  intense 
pain, 

"  The  sudden  development  of  a  hernia  invariably  causes 
pain  of  a  character  so  intense  as  to  be  almost  unbearable, 
to  which  the  affected  individual  involuntarily  gives  ex- 
pression, and  which  obliges  him  to  interrupt  his  work, 
and  to  consult  a  physician  at  once. 

"  If  no  proof  of  this  kind  is  forthcoming,  it  is  to  be 
presumed  that  the  work,  during  the  performance  of  which 
the  descent  of  the  hernia  occurs,  furnishes  the  occasion 
for  the  same,  but  does  not  act  as  its  cause,  and  is,  there- 
fore, to  be  regarded  as  the  cause  leading  to  the  discovery 
of  the  condition,  not  as  the  cause  of  the  hernia  itself." 
("  Manual  of  Accident  Insurance.") 

When  a  hernia  becomes  strangulated  as  the  result  of 
professional  work,  the  accident  is  entitled  to  be  considered 
as  the  cause  in  the  sense  of  the  law.  It  is,  therefore,  to 
the  interest  of  the  affected  individual,  in  respect  to  a  sub- 
sequent application  for  indemnity,  to  call  medical  aid  at 
once,  or,  at  the  latest,  on  the  following  day. 

The  average  insurance  allowance  for  an  inguinal  hernia 
the  retention  of  which  is  satisfactorily  guaranteed  by  a 
truss  is  10^.  A  hernia  that  continues  to  be  painful  calls 
for  a  higher  rate. 

In  examining  a  case  of  inguinal  hernia  the  following 
points  are  to  l)e  noted  : 

1.  External  location  and  structure  of  the  hernia. 

2.  Condition  of  the  hernial  opening  ;  size  and  condition 
of  the  abdominal  ring  or  of  the  inguinal  canal. 

3.  Sensitiveness  to  pressure  on  the  inguinal  canal  or  ab- 
dominal rinw. 

4.  Reducibility  of  the  hernia  when  the  patient  is  stand- 
ing- 

5.  Reducibility  when  the  })atient  is  prone. 

6.  Test  of  retention  of  hernia  by  a  well-fitting  truss. 

7.  Careful  history  in  regard  to  traumatic  origin. 


234  DISEA  8ES   C'A  USED  BY  A  CC I  DENTS. 


PLATE  15. 

Case  of  a  Large  Abdominal  Hernia  of  the  Right  Side 
Occurring  at  the  Site  of  a  Deep,  Funnel=shaped  Scar. 

A  hod-carrier,  twenty-se\  en  years  of  age,  addicted  to  drink,  sprang 
backward  from  an  insecnre  plank  into  a  trench,  striking  on  the  sliarp 
handle  of  a  spade.  The  handle  pierced  the  antero-external  part  of  the 
right  thigh,  passing  under  Ponpart's  ligament,  and  coming  out  just 
above  the  anterior  superior  spine  of  the  ilium.  The  patient  was  treated 
in  the  hospital  until  December  7,  1886.  I  examined  him  on  January 
6,  1887.  He  was  a  large,  vigorous  man.  In  the  right  side  of  the  ab- 
domen there  was  a  large,  broad,  funnel-shai)ed  scar,  which  extended 
deeply  into  the  tissues.  There  was  a  second  smaller  scar  on  the  an- 
tero-external aspect  of  the  right  thigh.  The  left  side  of  the  abdomen 
appeared  decidedly  distended.  The  patient  felt  well.  Insurance 
allowance,  at  lirst,  :>0,%.  About  six  weeks  later  I  was  hurriedly  sum- 
moned to  the  house,  and  found  in  place  of  the  funnel-shaped  scar  a 
hernia,  as  shown  in  the  illustration.  I  had  reason  to  believe  that  the 
hernia  was  caused  l)y  violent  peristalsis.  He  complained  of  abdominal 
pain  and  of  pain  in  the  right  thigh,  which  he  was  unable  to  move 
freel}'.  I  ordered  rest  in  bed,  compresses,  and  careful  diet.  The  insu- 
rance allowance  was  thereafter  reckoned  at  50%  for  three  years,  when 
it  was  raised  to  100%  on  the  ground  of  a  certificate  from  an  official 
examining  physician.  The  man  died  in  July,  1895,  of  chronic  neph- 
ritis. 

Femoral  hernia,  altliougli  usually  an  acquiretl  lesion, 
may  also  develop  as  a  result  of  traumatism.  The  insur- 
ance allowance  is  the  same  as  in  cases  of  inguinal  hernia. 

Umbilical  hernia  is,  as  a  rule,  congenital  or  acquired, 
and  is  frequently  observed  in  stout  peo])le  with  thick  ab- 
dominal walls.  Occasionally,  the  lesion  is  traceable  to  a 
trauma,  such  as  a  severe  contusion,  and,  as  a  rule,  in 
the  class  of  people  most  subject  to  the  acquired  form. 
An  umbilical  hernia  usually  disables  the  ])atient  to  a 
greater  extent  than  docs  an  inguinal  hernia,  and  it  is  often 
difficult  to  apply  a  suitable  truss,  especially  in  case  of  stout 
people.  Ventral  or  gastric  hernia  also  occurs  in  conse- 
quence of  traumatism,  although  by  some — by  Rinne,  for 
instance — this  is  denied.  Witzel,  on  the  other  hand, 
asserts  that  one-half  of  all  ventral  hernias  are  of  traumatic 
origin.  The  possil)ility  of  their  development  after  trau- 
matism  is   proved  by  a  number  of  my  own  cases.      The 


\  ^'f 


^\ 


■^ 


Tab.    lo. 


1,1th .  Aiisl  F.  Reich  hold,  Miimhi'n . 


HERNIA  AND  INSURANCE.  235 

symptoms  are  pain  in  the  stomach,  indigestion,  respiratory 
disturbances,  etc.  The  patients  are  unable  to  carry  heavy 
loads,  and  should  be  prohibited  from  doing  hard  work. 
Insurance  allowance,  33^^  to  50^.  Ventral  hernia 
may  appear  l)elow  the  region  of  the  stomach  ;  it  gives 
rise  to  practically  the  same  symptoms  in  all  situations. 

Case  of  traumatic  inguinal  hernia  of  the  left  side. 

A  liod-carrier,  twenty-one  years  of  age,  when  carryinp-  a  hod  full 
of  lime  on  his  left  shoulder  was  about  to  step  from  a  ladder  to  a  scaf- 
folding. At  that  moment,  when  his  right  foot  was  already  on  the 
scaffolding,  and  as  he  was  aboiit  t(j  lift  his  left  from  the  last  rung  of 
the  ladder,  the  latter  sli})ped  to  one  side.  This  caused  a  sudden  strain, 
immediately  followed  ))y  intense  pain  in  tlie  left  inguinal  region. 
Medical  aid  was  at  once  oljtained,  and  an  inguinal  hernia  Avas  diag- 
nosed. The  treatment  consisted  of  rest  and  the  subsequent  wearing 
of  a  truss.  \Mien  I  examined  the  patient,  I  found  a  small  hernia  the 
size  of  a  walnut  ;  on  palpation,  the  external  abdominal  ring  felt 
notched,  and  was  very  sensitive  to  pressure.  The  patieut  was  allowed 
20  ^/o  insurance  on  the  ground  of  the  .sensitiveness  of  the  lesion. 

[The  attitude  of  the  German  law  in  disregarding 
the  predisposition  to  hernia  and  in  granting  indemnity 
when  hernia  directly  follows  traumatism  in  the  hernial 
region  is  judicious.  Although  it  is  true  that  a  trau- 
matic protrusion  of  the  gut  rarely,  if  ever,  occurs,  except 
in  the  case  of  wounds,  without  a  congenital  or  acquired 
weakness  in  the  hernial  region,  it  would  be  going  rather 
beyond  the  mark  to  insist  on  this  point  in  awarding  dam- 
ages. On  the  other  hand,  there  is  no  doubt  that,  in 
this  country  at  least,  fully  developed  hernias  are  often 
alleged  to  be  the  result  of  an  accident  when  in  reality 
they  existed  before  the  accident.  To  obviate  this,  many 
corporations  now,  before  accepting  candidates  for  em- 
ployment, insist  on  their  physical  examination  with  espe- 
cial reference  to  the  various  hernial  regions. — Ed.] 


236  DISEASES  CAUSED  BY  ACCIDENTS. 


V.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
UPPER  EXTREMITY. 

I.  THE  SHOULDER. 

Bcmorls  on  the  Function  of  the  Slionli/rr. — Althongh  only  a  very 
limited  de<iree  of  motion  is  p()ssil)le  at  tlie  aeioiiiioehn  icular  articula- 
tion, the  latter  assists  the  slioulder-joint  in  the  elevation  of  the  arm 
above  the  horizontal. 

The  shoulder-joint  is  a  ball-and-socket  joint,  and  allows  of  rotation 
around  numerous  axes,  all  of  which  cross  one  another  at  one  point. 
This  joint  consequently  enjoys  a  wide  range  of  motion,  which,  how- 
ever, is  to  a  certain  extent  limited  by  the  anatomic  relations  of  the 
shoulder,  in  particular  by  those  existing  betA\'een  the  shoulder-joint 
and  the  acromion  process. 

The  head  of  the  humerus  is  held  in  its  socket  by  atmospheric  pres- 
sure and  by  the  deltoid  muscle,  assisted  l)y  the  suprasjjinatus.  The 
capsule  of  the  joint  is  very  thin,  and  is  too  relaxed  and  roomy  to  be 
of  service  in  this  resiiect.  AVith  the  arm  hanging  ])\-  the  side  the 
lower  jjart  of  the  capsule  is  relaxed  and  folded  on  itself;  it  becomes 
tense  when  the  arm  is  elevated,  while  the  ui)i)er  jtart  of  the  capsule  is 
thereby  relaxed. 

The  action  of  the  muscles  is  somewhat  different.  AVhen  the  arm  is 
hanging  down,  the  deltoid  and  supraspinatus  are  put  on  the  stretch, 
while,  if  the  forearm  is  at  the  sjime  time  extended,  the  tricejjs  and  the 
scapular  muscles  are  relaxed.  "When  the  arm  is  raised  to  a  le\  el  with 
the  shoulder,  the  deltoid  and  suprasjiiuatus  are  found  to  ))e  contracted, 
and  the  triceps  and  sc-ai)ular  muscles  are  i)ut  on  tlie  stretch.  Further 
discussion  of  these  points  A\ould  exceed  the  piu'pose  of  tliese  remarks, 
which  is  simply  to  indicate  in  brief  the  position  of  the  muscles  in  the 
different  attitudes  of  the  shoulder. 

The  arm  can  be  elevated  at  the  shoulder-joint  until  the  humerus 
comes  in  cf)ntact  with  the  acromial  process  ;  the  angle  thus  formed  is 
usually  one  of  ninety  degrees.  Further  elevation  is  acconi])]ished  Ijy 
rotation  of  the  sc\apula,  while  the  outer  end  of  the  cla\icle  moves 
Jjackward  and  upward.  The  arm  can  not  in  all  cases  l)e  raised  to  the 
horizontal  without  rotation  of  the  scapula.  According  to  my  observa- 
tions on  working-men  between  twenty-  and  thirty  .^cars  of  age,  the 
scapula  is  usually  called  into  play  when  an  angle  of  from  seventy -five 
to  eighty-five  degrees  is  reached. 

The  arm  is  rai.sed  to  a  level  with  the  shoulder  by  the  deltoid,  aided 
T»y  the  sujiraspinatiis,  the  latter  part  of  the  mo^'ement  being  accom- 
jdished  with  the  aasistance  of  the  serratus  magnus.  This  draws  the 
lower  angle  of  the  scapula  slightly  forward  and  outward,  while  the 
trapezius  either  holds  the  ujiper  ])art  of  the  scapula  firmly  in  position 
or  draws  it  toward  the  sjjine.  This  involves  motion  at  the  acromio- 
clavicular articulation.  According  to  Gaupp,  the  arm  is  at  the  siime 
time  dra%\n  slightly  for\vard  by  the  bicejjs  and  the  coracobrachialis, 
which,  therefore,  must  also  Ije  considered  to  take  part  in  the  elevation 


J 


THE  SHOULDER.  237 

of  the  arm.  Elevation  of  the  arm  al)o\-e  the  horizontal  takes  place  to 
a  considerable  extent  at  the  acromicx^lavicnlar  articulation,  the  acro- 
mial end  of  the  clavicle  being  drawn  back  In*  the  trapezius,  while 
the  serratus  niagnus  draws  the  scapula  forward  and  rotates  it  tipward. 
The  inferior  angle  of  the  scapula  is  thereby  made  to  move  from  behind 
forward  in  a  circle  the  convexity  of  which  is  directed  downward. 

The  final  elevation  of  the  arm  to  a  \  ertical  position  is  executed  at 
the  sternoclavicular  articulation;  the  clavicle  rotates  in  its  long  axis, 
so  that  the  anterior  margin  comes  to  be  directed  upward. 

In  raising  the  arm  above  the  horizontal  the  trapezius  is  assisted  by 
the  levator  anguli  scapuhe  and  the  rhomljoid  muscles,  especially  the 
rhomlioideus  minor. 

The  arm  is  elevated  anteriorly  by  the  trapezius,  the  levator  anguli 
scapulae,  and  the  pectoralis  major  (addtiction),  the  scapula  being  ro- 
tated at  the  same  time  by  the  serratus  magnus. 

The  shoulder  as  a  whole  is  raised  Ijy  the  levator  anguli  scapulae  and 
the  upper  and  middle  fillers  of  the  trapezius,  aided  in  certain  cases  by 
the  sternocleidomastoid.  The  .shoulder  as  a  whole  is  depres.sed  by  its 
own  weight ;  the  pectoralis  minor  and  the  subclavian  muscles  may 
also  be  called  into  play.  It  is  carried  forward  by  nieaas  of  anterior 
rotation  of  the  sc-apula  and  the  acromioclavicular  joint,  the  movement 
being  produced  by  the  action  of  the  serratus  magnus,  by  the  anterior 
fibers  of  the  trapezius,  and,  doubtless,  also  by  the  pectoralis  minor. 
During  this  movement  the  inner  margin  of  the  scapula  is  drawn  away 
from  the  spine.  In  carrying  the  shoulder  Ijackward  the  inner  margin 
of  the  scapula  approaches  the  spine  and  the  acromioclavictilar  joint 
moves  backward.  The  muscles  concerned  are  the  middle  and  inferior 
fibers  of  the  trapezius,  the  rhomboidei,  and  the  latissimus  dorsi. 

Limitation  or  loss  of  the  functional  action  of  the  shoulder-joint  is 
due  to  : 

1.  Primary  causes,  consisting  of  pathologic  processes  or  changes  in 
the  shoulder-joint  itself. 

2.  Secondary  causes,  consisting  of  pathologic  conditions  of  struc- 
tures external  to  the  joint. 

The  primary  causes  include  acute  and  chronic  inflammations,  adhe- 
sions, contractures,  ankylosis,  paralyses  of  the  nerves  and  muscles  of 
the  joint,  relaxation  of  the  capsule  ( loose-jointedness ) ,  etc.  To  the 
secondary  causes  belong  cicatricial  adhesions  of  neighboring  structures; 
fixation  of  the  head  of  tlie  luimerus  in  a  position  of  subhixation  after 
fracture  of  the  latter,  accompanied  Ity  displacement  of  the  broken 
ends;  displacement  of  the  shoulder-joint  in  consequence  of  fracture  of 
the  clavicle,  sciipula,  or  elbow-joint;  central  paralyses,  etc. 

Siafixticfi. — The  following  sections  are  based  on  an  experience  with 
1671  injuries  of  the  upper  extremity.  Of  these,  the  shoulder-joint 
was  involved  in  312,  the  arm  in  l(i7,  the  elV)ow-joint  in  103,  the  fore- 
arm in  261,  the  wrist  in  87,  and  the  hand,  including  the  fingers,  in  721 
cases. 


238  DISEASES   CAUSED  BY  ACCIDENTS. 


I.  Contusions  of  the  Shoulder  and  Shoulder=joint. 

Remarks  Regarding  Examination. — In  examining  a  patient  we  should 
begin  by  a  careful  insi)ection  of  the  affected  shoulder,  comparing  it 
with  the  normal  side  :  lirst  with  the  arms  hanging  down,  then  held 
level  with  the  shoulder,  and  subsetpiently  in  other  positions,  care  being 
taken  that  the  arms  exactly  corresi)on(l  in  position.  The  anterior  and 
posterior  awjiects  of  the  shoulder  and  the  jxjsition  of  the  clavicle, 
scapula,  etc.,  should  all  be  carefully  determined  in  succession. 

Contusions  of  the  shoulder  or  of  the  shoulder-joint  were  represented 
by  159  of  my  cases. 

Falls,  kicks,  blows,  and  objects  falling-  from  above  or 
from  the  side  may  involve  the  whole  shoulder  or  only  its 
outer  end,  or,  in  other  words,  only  the  shoulder  proper 
or  shoulder-joint.  Much  depends,  in  regard  to  this 
point,  on  the  kind  of  force  at  w<n'k  and  on  the  direction 
in  Avhicli  it  acts,  as  well  as  on  its  intensity. 

The  whole  shoulder  is  usually  involved  Avhen  it  is  in- 
jured l)y  being  caught  and  crushed  between  moving  objects, 
or  when  heavy  material  falls  upon  the  prone  body,  or  in 
cases  of  injury  due  to  a  caving-in.  The  shoulder-joint  is 
alone  affected,  on  the  other  hand,  in  most  cases  of  trauma- 
tism caused  by  l)lows  from  objects  falling  in  a  vertical 
line. 

The  injury  may  amount  simply  to  a  contusion,  or  may 
be  more  severe,  according  to  the  degree  of  violence  and 
the  place  to  which  it  is  applied.  Among  the  cases  of 
contusion  coming  under  my  observation  I  have  found 
many  fractures,  dislocations,  and  paralyses,  and  occasion- 
ally lacerations  of  the  muscles.  Neither  are  the  con- 
sequences of  the  injury  confined  to  the  ])art  immediately 
involved  ;  the  clavicle,  for  instance,  may  be  dislocated  at 
its  sternal  end  by  a  fall  on  the  shoulder.  Thus,  28  of 
my  cases  were  followed  by  paralysis,  w^hile  in  11)  cases 
there  was  a  fracture  of  the  scapula  and  in  18  a  dislocation 
at  the  acromioclavicular  articulation. 

In  light  cases  of  simple  contusion  of  the  shoulder  or 
shoulder-joint  healing  usually  takes  jilace  very  quickly  ; 
in  some  individuals  it  is  a  question  of  only  a  few  days, 


CONTUSIONS  OF  THE  SHOULDER.  239 

while  in  others  recovery  is  not  completed  for  a  number  of 
weeks.  If  properly  treated  by  compresses,  early  massage, 
and  exercises,  the  pain  disappears,  the  exudation  is  soon 
absorbed,  and  the  patient  is  often  ready  to  resume  work  in 
a  few  weeks.  Recovery  is  delayed  by  complications  or 
when  the  joint  is  kept  at  rest  for  too  long  a  time.  I>ong- 
continued  fixation  leads  to  ankylosis,  which  is,  however, 
only  of  permanent  nature  in  case  of  old  persons  or  in 
those  affected  by  some  constitutional  disease. 

Leaving  fractures,  dislocations,  and  paralyses  out  of 
consideration,  the  effect  of  the  contusion  is  spent  on  the 
skin,  muscles,  fascise,  capsule,  tendons,  and  bursse. 

After  the  extravasation  is  absorbed  and  the  inflamma- 
tion is  subdued  certain  symptoms  remain,  which,  if  severe, 
may  call  for  after-treatment,  but  which,  if  only  slightly 
marked,  do  not  prevent  the  patient  from  resuming  work. 
They  are  as  follows  :  more  or  less  atrophy  of  the  deltoid, 
possibly  also  of  the  trapezius  and  the  muscles  of  the  arm 
and  chest ;  limited  mobility  of  the  shoulder-joint ;  pain 
on  forced  movement ;  cracking  sounds  of  more  or  less  in- 
tensity ;  and  a  feeling  of  weakness  in  the  arm.  In  some 
cases  displacement — fixation  of  the  arm  in  pronation  or 
supination — is  also  seen  as  a  result  of  the  growth  of 
adhesions. 

The  average  insurance  allowance  is  about  25^,  which 
can  usually  be  reduced  or  discontinued  three  months  after 
the  accident.  Occasionally,  life-long  compensation  is  de- 
manded, when  the  patient  is  old  or  delicate  or  rheumatic, 
or  when  the  injury  is  followed  by  some  serious  disorder. 

Case  of  crushinf/  of  the  left  shoulder  eaitseif  In/  the  earing-in  of  the  side 
of  n  trench.  .Sequels,  paralysis  of  the  l)raehial  plexus  ;  trojihoiienrosis 
of  the  hand. 

A  \\orkiiian,  fifty -two  years  of  age,  was  injured  on  July  2(1,  1898, 
by  the  caving-in  of  the  sides  of  the  trench  in  which  he  was  working. 
He  was  treated  for  two  weeks  with  inunctions,  and  subsequently  by 
electricity.  I  examined  him  on  October  7,  1898.  His  left  arm  conld 
not  be  raised  at  the  shoulder-joint,  and  its  extreme  elevation  ecjualed 
only  seventy-five  degrees.  Tlie  inusc-les  of  the  left  shoulder  and  of  the 
left  side  of  the  chest  were  atrophied.    There  was  a  noticeable  edematous 


240  DISEASES   CAUSED  BF  ACCIDENTS. 

swelling  of  the  left  hand,  which  symptom  had  not  appeared  until  two 
Aveeks  after  injury.  The  finger-joints  were  thickened,  and  the  hand 
could  not  be  closed.  The  parts  snpjilied  by  the  median  and  iilnar 
nerves  were  paralyzed.  (See  Plate  30,  Fig.  2.)  The  patient  was  treated 
by  me  until  the  beginning  of  September,  1H99.  At  that  time  he 
showed  marked  impro\  ement ;  he  could  close  his  hand  three-fourths, 
and  could  raise  the  arm  at  the  shoulder-joint  to  an  angle  of  155  degrees. 

Injuries  of  the  burspe  prolong  the  course  of  treatment 
to  a  considerable  extent.  When  the  acromial  bursa  is  in- 
volved, it  appears  as  a  small,  sharply  rounded  tumor  on  the 
acromion  process.  This  condition  is  often  seen  in  porters  ; 
it  causes,  however,  very  little  trouble.  Inflammation  of 
the  subacromial  bursa  is  said  by  Dupley  to  lead  to  a  hyper- 
plasia of  the  fibrous  tissue  of  the  brachial  plexus,  and 
thereby  to  neuritis  of  the  latter.  The  subcoracoid  bursa 
is  probably  also  involved  in  this  process.  The  symptoms 
are  as  follows  :  sensitiveness  to  pressure  under  the  acromial 
and  coracoid  processes  and  upon  the  acromial  insertion  of 
the  deltoid  ;  pain  on  forced  movement  of  the  shoulder ; 
movement  of  the  whole  shoulder  takes  place  when  the  arm 
is  abducted  above  an  angle  of  forty-five  degrees     (Tliiem). 

When  the  subdeltoid  bursa  or  the  bursa  of  the  bicipital 
groove  is  concerned,  the  chief  symptom  is  pain  on  move- 
ment of  the  shoulder  or  arm. 

Injuries  to  the  subscapularis  bursa  are  of  special  im- 
portance because  of  the  danger  of  extension  of  the  inflam- 
mation to  the  capsule  of  the  shoulder-joint  with  which  the 
bursa  is  connected.  A  prolonged  course  of  treatment  is 
nsually  necessary  in  such  a  case  ;  the  muscles  of  the 
whole  shoulder  atrophy,  and  the  mobility  of  the  shoulder- 
joint  is  restricted  for  a  long  time — at  first  on  account  of 
pain  ;  later,  on  account  of  adhesions  formed  within  the 
joint. 

Among  other  syn)ptoins  observed  after  recovery  from 
bursitis  belong  the  loud  cracking  sounds  produced  by 
movement,  especially  when  the  bursa  situated  at  the  su- 
perior angle  of  the  scapula  is  involved.  The  sounds  are 
often  audible  at  a  considerable  distance,  but   are   not  of 


SPRAINS  OF  THE  SHOULDER.  241 

any  functional  significance,  the  u.sefulness  of  the  joint  re- 
maining unimpaired.  This  is  true,  indeed,  of  clirouic  bur- 
sitis in  general. 

2.  Sprains  of  the  Shoulder. 

Among  my  cases  there  were  twenty-two  of  uncomplicated  sprains 
of  the  slioulder. 

Sprains  due  to  falls  or  blows  on  the  shoulder,  elbow,  or 
hand  may  involve  either  the  whole  shoulder,  or  the 
shoulder-joint  or  acromioclavicular  joint  alone.  The 
same  is  true  of  the  lesion  when  caused  by  suddenly  catch- 
ing at  an  oI)ject,  by  vigorous  pulling  on  an  object  that  is 
firmly  fixed  in  place,  etc. 

The  following  symptoms  are  common  to  all  forms  of 
sprain  of  the  shoulder  in  the  later  stages  of  the  injury  ; 
limitation  of  mobility  of  the  shoulder-joint,  cracking 
sounds  on  movement,  })ain  (this  may  be  lacking),  and 
atrophy  of  the  muscles. 

Sprains  of  the  Acromioclavicular  Articulation. 

The  effects  of  this  lesion  may  be  limited  to  the  stretch- 
ing and  straining  of  the  acromioclavicular  ligaments,  pos- 
sibly causing  partial  laceration  of  the  latter,  or  may  be 
extended  also  to  the  acn^nial  and  subacromial  bursse.  If 
the  ligament  is  only  slightly  torn,  the  mobility  of  the 
joint  is  seldom  permanently  impaired.  Acute  bursitis  is 
followed  by  chronic  inflammation,  shown  by  the  cracking 
sounds  already  referred  to,  which  are  most  noticeable 
when  the  subacromial  bursa  is  involved.  As  a  rule,  this 
condition  causes  only  slight  functional  disability  ;  this  is 
largely  an  individual  matter,  however,  and  in  some  cases 
a  temporary  insurance  allowance  of  20  ^  is  indicated. 


3.  Fractures  of  the  Clavicle. 

Of  this  lesion  seventy-four  cases  liave  come  under  my  personal  ob- 
servation. 
16 


242  DISEASES  CAUSED   BY  ACCIDENTS. 

Fractures  of  the  clavicle  are  quite  a  cominou  form  of 
injury  ;  in  surij;i(^al  text-l)ooks  they  are  stated  as  consti- 
tuting 15^  of  all  fracture-cases.  As  a  rule,  they  are 
caused  by  indirect  violence  ;  but  direct  fractures  also  occur 
at  any  part  of  the  bone — most  frequently  at  the  outer  end. 

Direct  fractures  of  the  outer  end  are  due  either  to 
blows  from  falling  objects  or  to  falls  on  the  shoulder. 
The  indirect  form  is  usually  produced  by  falls  on  the 
hand  when  the  forearm  is  extended. 

The  most  connnon  seat  of  fracture  is  the  middle  third 
of  the  Ijone,  or  a  point  between  the  middle  and  outer 
thirds,  the  lesion  being  due,  as  a  rule,  to  indirect  violence, 
— such  as  a  fall  on  the  hand  with  extended  forearm,  or 
a  fall  on  the  shoulder, — or,  less  frequently,  to  the  strain 
of  lifting  heavy  weights. 

Fractures  of  the  inner  third  are  of  conq)aratively  in- 
frequent occurrence.  They  are  caused  by  indirect  vio- 
lence, usually  by  violent  contraction  of  the  sternocleido- 
mastoid. 

Symptoms  of  Reunited  Fractures  of  the  Clavicle. 
— In  order  to  gain  a  clear  understanding  of  the  dis})lace- 
ments  consequent  upon  fracture  of  the  chivicle  it  is  neces- 
sary to  think  of  this  bone  as  a  brace  l)etween  the  sternum 
and  the  acromion  process  of  the  scapula.  It  is  easy  to 
see  that  a  fracture  accompanied  by  displacement  of  the 
broken  ends  must  necessarily  involve  an  abnormal  posi- 
tion of  the  scapula,  of  the  liumerus,  and,  indirectly,  of  the 
head  also. 

Of  the  symptoms  of  fracture  of  the  clavicle  with  which 
we  have  to  deal  after  union  has  taken  place,  those  de- 
scribed below  are  of  most  frequent  occurrence. 

At  the  point  of  fracture  there  is  a  more  or  less  marked 
callus-tumor,  which  diminishes  in  size  in  the  course  of 
time,  and  may  entirely  disappear  aftei'  a  few  years.  In 
some  cases  the  callus  is  not  preceptible  externally  ;  we 
find,  instead,  a  pointed  or  sharp-edged  ])r()minence,  con- 
sisting of  one  of  the  fragments  of  the  fractured  bone  over- 


SPRAINS  OF  THE  SHOULDER.  243 

the  other.  As  a  rule,  the  inner  fragment  overlies 
the  outer.  This  displacement  of  the  fragments  has  the 
effect  of  shortening  the  clavicle,  and,  consequently,  the 
position  of  the  shoulder  is  altered.  The  scapula  adapts 
itself  to  these  new  conditions  by  rotating  on  its  long  axis, 
the  external  margin  turning  forward,  while  the  head  of 
the  humerus,  in  following  the  change  of  position,  rotates 
slightly  inward.  When  both  arms  are  placed  on  a  level 
with  the  shoulder,  with  the  thumbs  turned  upward,  the 
l)icipital  aspect  of  the  arm  is  seen  to  be  directed  down- 
ward, while  the  olecranon  process  looks  upward.  The 
shortening  of  the  shoulder  and  the  deformity  due  to  in- 
ward rotation  are  clearly  seen  in  this  position.  In  typical 
cases  of  fracture  in  the  middle  third  of  the  clavicle  the 
shoulder  is  depressed. 

When  the  inner  fragment  is  displaced  forward,  the 
sternocleidomastoid  becomes  very  prominent  and  draws 
the  head  slightly  to  the  side,  making  the  neck  appear 
shortened  on  the  side  of  the  fracture,  and  lengthened  on 
the  opposite  side  (caput  obstipum). 

The  trapezius,  as  well  as  the  muscles  of  the  shoulder, 
chest,  and  arm  of  the  injured  side,  give  evidence  of 
atrophy,  in  consequence  of  which  the  shoulder  frequently 
has  a  pointed  appearance. 

The  mobility  of  the  shoulder-joint  is  restricted,  the 
movements  of  elevation  of  the  arm  above  the  shoulder  and 
of  rotation  outward  and  inward  being  especially  affected. 
Movement  may  continue  to  cause  pain  for  some  time,  and 
neuralgic  tenderness  can  sometimes  be  traced  down  to 
the  ends  of  the  fingers.  Cracking  sounds  are  often  pro- 
duced at  the  shoulder,  and  the  whole  upper  extremity  re- 
mains weak  for  a  time. 

The  deltoid  is  sometimes  paralyzed  as  a  result  of  direct 
contusion. 

Case  of  reunited  frdciure  of  Ihe  rifiht  clavicle  at  ifpt  outer  end,  with  dis- 
pJaeement  of  the  outer  fragment  into  the  supranpinouH  fosm. 

A  paiuter,  Hfty-four  years  of  age,  was  crushed  between  a  track  and 


244  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  IG. 

Case  of  Reunited  Fracture  of  the  Left  Clavicle  in  Its 
Middle  Third. 

A  ina.s(jn,  t\\enty-four  j'ears  of  age,  fell  from  a  height  of  one 
story  on  Bepteml)er  lo,  1897,  sustaining  a  fracture  of  the  left  clavicle. 
He  was  treated  in  the  hospital  for  some  weeks.  I  examined  him  on 
October  16,  1897.  He  had  been  incapacitated  for  work  for  exactly 
four  W'Ceks. 

In  the  illustration  the  displacement  of  the  sternal  fragment  for- 
ward and  upward  and  the  marked  elevation  at  the  point  of  fracture 
are  shown.  The  sternocleidomastoid  is  distinctly  seen,  and  the 
head  is  somewhat  inclined  to  the  left.  The  left  shoulder  and  left  arm 
are  slightly  rotated  inward,  and  there  is  evidence  of  atrophy  of  the 
muscles  of  the  left  shoulder  and  arm.  The  shoulder  appears  a  little 
shortened.  At  the  time  the  patient  came  to  me  for  examination 
he  was  able  to  raise  his  left  arm  at  the  shoulder-joint  to  an  angle  of 
140  degrees.  He  undertook  light  work  at  first  and  comjilained  chiefly 
of  pain  on  movement  of  the  left  shoulder  and  of  inability  to  use  the 
latter  for  carrying  purpryses.  He  was  allowed  20%  insurance.  At 
the  present  time  he  is  unable  to  raise  his  arm  above  an  angle  of  160 
degrees. 


a  Avail.  He  sustained  a  fractui-e  of  the  right  clavicle  and  fractures 
near  the  spine  of  the  third  to  eighth  ribs  inclusive.  He  was  treated 
in  the  hospital  for  several  weeks.  I  examined  him  July  17,  1896. 
He  was  of  medium  height.  Face  rather  pale.  The  deformity  of  the 
right  shoulder  was  very  evident ;  of  the  clavicle,  only  the  larger 
sternal  fragment  was  visible,  while  the  acromial  process  was  sharply 
defined.  On  palpation  a  fibrous  cord  could  be  felt,  passing  from  the 
acromial  process  to  the  outer  third  of  the  clavicle,  while  ])art  of  the 
outer  fragment  lay  in  the  siipraspinous  fossa,  which  it  filled.  The 
muscles  of  the  scapula,  the  back,  and  the  whole  shoulder  -were  much 
atrophied,  and  the  shoulder  ai)peared  to  be  displaced  Ijack^vard.  The 
patient  could  not  raise  his  right  arm  above  an  angle  of  thirty-five 
degrees  ;  on  passive  motion  it  could  be  carried  with  great  difficulty  to 
an  angle  of  sixty -five  degrees  and  caused  the  patient  a  great  deal  of 
pain. 

The  movement  produced  cracking  sounds  in  the  joint.  The  scapula 
was  called  into  action  before  thirty-fi\e  degrees  were  reached.  The 
sternocleidomastoid  was  displaced  forward,  and  the  head  was  slightly 
inclined  to  the  right  side.  After  a  further  course  of  treatment  the 
patient  was  discharged  from  my  clinic  on  April  26,  1HJ)7,  receiving  50% 
insurance  allowance.  He  was  then  able  to  raise  his  arm  with  ease 
to  an  angle  of  115  degrees,  and  could  carry  it  to  145degrees  with  effort. 
The  pain  had  greatly  diminished.  The  skiagraph  clearly  shows  the 
displaced  outer  fragment  of  the  clavicle,  the  acromial  end  of  which 
lies  close  to  the  coracoid  process.    The  points  of  fracture  of  the  ribs  near 


Tab.  16. 


I.ith  Aii.sl  H  HpicJtIicild .  Miiiirhcii 


^■ 


l. 


FRACTURES  OF  THE  CLAVICLE.  245 

the  spinal  cohimii,  showing  their  upward  dislocation,  can  also  l)e  rec- 
ognized. 

AMien  the  jiatient  entered  my  care  he  complained  of  pain  in  the 
chest  and  on  stooping,  which  disappeared,  however,  by  Jannary^, 
1897.  In  September,  1897,  the  patient  was  allowed  'So^c  insurance; 
in  September,  1898,  tliis  was  reduced  to  25  % .  At  that  time  the  arm 
could  l»e  raised  \-oluntarily  to  an  angle  of  150  degrees,  and  on  passive 
motion  to  160  degrees. 

In  comparatively  rare  instances  we  may  meet  with 
paralyses  of  the  brachial  plexus  due  to  direct  injury. 

[Symptoms  referable  to  the  brachial  plexus  resulting 
from  injury  to  the  shoulder  are  not  so  very  rare,  and  are 
often  puzzlino'.  They  result  from  direct  violence,  such 
as  blows  or  falls,  with  or  without  fracture  or  dislocation 
of  bone,  rather  than  from  the  slow  pressure  of  callus. 
The  musculosj)iral  and  ulnar  are  the  nerves  most  fre- 
quently involved  in  injuries  around  the  shoulder-joint, 
although  paralysis  of  the  circumflex  or  the  median  or  the 
musculocutaneous  may  be  added.  The  symptoms  of  these 
combined  paralyses  are  the  sum  of  the  symptoms  of  palsy 
of  the  individual  nerves.  They  are  usually  the  result  of 
severe  injuries,  and  the  prognosis  is  accordingly  serious. 

Injuries  to  the  neck,  falls  upon  the  point  of  the  shoulder, 
and,  less  frequently,  dislocations  of  the  shoulder  sometimes 
cause  a  peculiarly  distributed  paralysis,  first  described 
by  Erb,  and  often  called  Erl)'s  palsy.  The  muscles  most 
frequently  aifected  are  the  deltoid,  biceps,  brachialis  an- 
ticus,  and  supinator  longus.  -  The  supraspinatus  and  in- 
fraspinatus may  also  be  involved.  (Then  there  is  an 
inward  rotation  of  the  arm.)  All  these  muscles,  with  the 
exception  of  the  last  two,  receive  their  innervation  through 
the  fifth  and  sixth  cervical  nerve-roots.  The  supra- 
scapular nerve,  which  supplies  the  supraspinatus  and 
infraspinatus,  receives  some  fibers  from  the  fourth  cervical 
segment,  but  as  most  of  its  fibers  come  through  the  fifth 
and  sixth  roots,  it  may  easily  be  injured  when  these  roots 
are  aflPected.  Hoedemaker  has  suggested  that,  in  injuries 
to  the  shoulder,  paralysis  of  these  nerves  may  occur  by 


246  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  17. 

Case  of  Fracture  of  the  Sternal  Extremity  of  the  Left  CIavi= 
cle  Leading  to  Ankylosis  of  the  Shoulder=joint  and  Torticollis, 
Requiring  a  Prolonged  Course  of  Treatment.  JNIaikod  iiiipio\ e- 
meiit  later  on. 

A  workman,  iifty-five  years  of  age,  on  July  7,  1892,  fell,  with  the 
ladder  on  which  he  was  standing,  striking  the  sidewalk  on  his  left 
shoulder.     He  was  treated  in  the  hospital  for  se\ en  weeks. 

The  patient  was  a  small,  delicate  man.  The  illustration  shows  his 
condition  at  the  heginning  of  a  course  of  treatment  in  my  hospital, 
which  lasted  from  ( )cto])er,  1892,  to  May,  1893.  The  almost  complete 
uselessness  of  the  left  arm  and  shoulder  was  very  e^'ident  at  that  time. 
In  the  pictirre  the  thickened  prominent  sternal  end  of  the  left  clavicle 
can  be  seen,  drawing  the  sternocleidomastoid  for\vard.  The  head  is 
perceptibly  inclined  to  the  left,  while  the  acromial  end  of  the  clavicle 
is  elevated  and  displaced  back^^•ard.  The  left  shoulder  is  shortened, 
the  muscles  of  the  left  arm  and  shoulder  are  atrophied,  and  the  arm  is 
held  rather  close  to  the  Ijody.  Posteriorly,  the  atrophy  of  the  trape- 
zius and  of  the  muscles  of  the  whole  slioulder  is  distinctly  visible. 

The  treatment  consisted  in  passive  movements  and  gymnastic  exer- 
cises of  the  left  shoulder,  and  in  massage  and  electricity. 

The  patient  was  discharged  in  May,  1893,  with  an  insurance  allow- 
ance of  50%,  which  he  drew  until  July,  1898,  when  it  was  reduced  to 
25%.  At  the  present  date  the  arm  can  l)e  raised  almost  to  a  line  with 
the  body,  the  head  is  held  straight,  the  l)ackward  displacement  of  the 
acromial  end  of  the  left  clavicle  has  disappeared,  and  the  arm  is  held  in 
an  entirely  normal  position.  The  only  remaining  symptom  is  a  slight 
weakness  of  the  arm. 

the  fifth  and  sixth  roots  .being  compressed  between  the 
transverse  processes  of  the  sixth  and  seventh  cervical  vcr- 
tebne  and  the  middle  of  the  clavicle. 

In  cases  in  ^vllich  the  paralysis  is  severe,  Erb's  ])alsy  is  a 
very  disablino;  affection.  The  arm  can  not  be  raised  from 
the  side,  and  the  forearm  can  not  be  flexed  or  strongly 
rotated  outward.  From  paralysis  of  the  deltoid,  the 
slioulder  of  the  affected  side  is  lower  than  its  fellow,  and 
there  may  be  a  sliy-ht  subo::lenoid  dislocation  of  the  humerus. 
Atrophy  is  often  an  early  sym])tom,  and  there  is  usually 
marked  fibrillary  twitching  in  the  muscles  when  they  are 
put  in  action,  if  that  is  possible  ;  they  sometimes  are 
completely  paralyzed.  The  sensory  symptoms  are  never 
prominent ;  there   may  be  numbness  and  tingling  in  the 


5$ 


■  i0^- 


ERB'S  PARALYSIS.  247 

region  of  the  shoukler  or  in  the  radial  distribution  of  the 
forearm  and  hand.  The  eleetrie  reaction  soon  sliows 
degenerative  changes.  All  these  muscles  may,  in  health, 
be  made  to  contract  by  applying  the  electric  current  at  a 
point  in  the  neck  called  Erb's  point  ;  after  injury  disor- 
dered electric  reactions  soon  become  manifest  at  this  point. 

The  general  prognosis  of  this  form  of  paralysis  is  good, 
in  that  the  patients  usually  recover.  Recovery  is,  how- 
ever, always  tedious,  extending  over  many  months. 

Another  form  of  brachial  plexus  palsy,  named,  after  its 
first  describer,  Klumpke's  palsy,  involves  the  first  anterior 
dorsal  root.  Through  this  root  ])ass  the  sympathetic  fibers 
for  the  eye  and  face.  The  symptoms  are  paralysis  of  the 
small  muscles  of  the  hand  and  disturbances  of  tlie  sympa- 
thetic in  the  face  of  the  same  side.  There  are  myosis, 
diminution  in  size  of  the  palpebral  fissure,  loss  of  the  cilio- 
spinal  reflex,  sinking-in  of  the  eyeball,  and  flattening  of 
the  side  of  the  face.  There  are  usually  no  vasomotor  dis- 
turbances. 

Klumpke's  paralysis  results  from  causes  similar  to  those 
of  Erb's  paralysis,  but  it  is  nuich  less  frequent. — Ed.] 

Symptoms  ascribable  to  pressure  of  the  callus  on  the 
plexus  are  also  observed  at  times.  Pseudo-arthrosis  is 
another  unusual  sequel. 

The  following  points  call  for  special  mention  : 

Fractures  of  the  external  third  of  the  clavicle  usually 
lead  to  only  slight  displacement,  except  when  the  bone  is 
broken  between  the  two  divisions  of  the  coracoclavicular 
ligament, — namely,  the  conoid  and  trapezoid  ligaments, — 
and  the  latter  are  thereby  lacerated.  In  these  cases  the 
outer  fragment  sometimes  l)ecomes  fixed  at  a  right  angle 
to  the  inner  fragment,  the  acromial  extremity  pointing  up- 
ward, thereby  elevating  the  scapida  and  the  whole  shoulder. 
In  other  cases  the  acromial  extremity  is  directed  down- 
ward, or  it  is  entirely  displaced  and  lies  in  the  supraspi- 
nous fossa.  Where  such  marked  deformity  exists,  the 
mobility  of  tlie  shoulder-joint  is  greatly  restricted  ;  com- 


248  DISEASES  CAUSED  BY  ACCIDENTS. 

plete  ankylosis  may  even  supervene  as  a  result  of  bony 
union  with  the  coracoid  process  or  with  the  shoulder- joint 
itself. 

The  consequences  of  fractures  of  the  inner  third  of  the 
bone  depend  to  a  larji;e  extent  upon  the  action  of  the 
sternocleidomastoid.  At  first  the  head  is  inclined  toward 
the  injured  side  in  order  to  avoid  pain,  and  the  position 
once  taken,  it  is  frequently  retained.  In  addition,  we  find 
a  growth  of  callus  at  the  point  of  fracture,  and  in  some 
cases  partial  forward  dislocation  of  the  sternal  extremity 
of  the  clavicle.  Further,  there  is  atrophy  of  the  muscles 
of  the  shoulder,  neck,  and  chest  on  the  injured  side,  and 
limited  mobility  of  the  shoulder-joint,  movement  of  which 
produces  crackino;  sounds.  The  ankylosis  of  the  shoulder- 
joint  is  almost  always  due  to  unnecessarily  prolonged  fixa- 
tion, to  which  cause  contractures  of  the  elbow-joint, 
frequently  observed  after  removal  of  the  fixation-bandage, 
are  also  to  be  ascribed. 

Fractures  of  the  clavicle  may  be  further  complicated 
by  fractures  of  the  ribs.  In  case  of  the  first  rib  the 
lesion  is  due  to  direct  })ressure  ;  fractures  of  the  other 
ribs,  however,  are  indirectly  caused  by  falls  on  the 
shoulder.  These  complicating  fractures  are  frequently 
overlooked. 

The  chief  aim  of  treatment  should  be  the  restoration 
of  function.  Massage  is  particularly  to  be  recommended 
if  the  parts  are  still  swollen,  while  ankylosis  is  best 
treated  by  systematic  j)assive  movements  and  gymnastic 
exercises.  Massage  and  electricity  should  be  employed  for 
muscular  atrophy  ;  for -neuralgia,  galvanism  and  baths  are 
especially  beneficial. 

After-treatment  may  be  indicated  for  a  few  weeks  only, 
or,  when  com])lications  exist,  for  a  number  of  months. 
Even  prolonged  treatment  may  prove  unsuccessful  iu  un- 
favorable cases,  the  shoulder-joint  remaining  permanently 
ankylosed. 

It  should  not  be  forgotten,  however,  in  considering  the 


DISLOCATIONS   OF  THE   CLAVICLE.  249 

serious  consequences  of  the  injury,  that  working-men 
liave  been  known  to  continue  work  after  sustaining  a 
fracture  of  the  chiviele. 

Case  of  frdctitrc  of  f/ir  outer  third  of  the  elnriele  in  consequence  of  a 
fall  from  a  ladder.  No  niedifal  advice  was  obtained,  work  was  not 
discontinued,  and  recovery  took  place  witliout  deformity. 

A  workman,  eighteen  years  of  age,  fell  from  a  ladder  in  1864. 
Although  the  clavicle  was  fractured,  he  felt  only  slight  pain  and  went 
on  with  his  work.  Tlie  fracture  healed  while  work  was  continued, 
the  bone  being  but  little  displaced.  It  was  shortened  by  Ik  cm. 
The  functional  power  of  the  patient  was  unaffected.  He  entered  the 
army  later,  and  took  pail  in  the  two  subsequent  ware. 

4.  Dislocation  of  the  Clavicle. 

Of  this  lesion  fifteen  cases  have  come  under  my  observation. 

The  clavicle  may  suffer  a  forward  dislocation  at  its 
sternal  extremity  in  consequence  of  a  fall  on  the  anterior 
part  of  the  shoulder,  of  being  run  over,  and  similar 
accidents  by  which  the  shoidder  is  violently  driven  back- 
ward, while  the  shaft  of  the  bone,  acting  as  a  lever,  forces 
the  sternal  extremity  forward  out  of  its  normal  position. 
Partial  dislocations  of  this  joint  on  the  side  supporting  the 
load  are  frequently  observed  in  hod-carriers. 

The  symptoms  of  forward  dislocation  after  healing 
takes  place  are  as  follows  :  As  it  is  almost  impossible  to 
succeed  in  retaining  the  dislocated  bone  in  position  after 
reduction,  it  remains  disj)laced  forward  to  a  greater  or  le.ss 
degree  for  a  long  time.  The  undue  mobility  of  the  joint 
that  accompanies  the  displacement  may  persist  for  some 
years.  The  sternocleidomastoid  is  prominent,  and  is  some- 
what displaced  forward,  thereby  causing  tiie  neck  to 
appear  shortened  on  that  side,  while  the  reverse  effect 
obtains  on  tlie  opi)osite  side.  The  triangle  formed  by  the 
sternocleidomastoid,  the  clavicle,  and  the  anterior  margin 
of  tlie  trapezius  is  diminished  in  size. 

The  acromial  extremity  of  the  clavicle  may  be  directed 
backward  and  downward,  or  backward  and  upward,  the 
shoulder  being  correspondingly  lowered  or  raised. 


250  DISEASES  CAUSED  BY  ACCIDENTS. 

The  imisc'les  <»f  the  chest,  shoulder,  and  neck  on  the 
injured  side  show  evidence  of  atrophy,  and  movement 
of  the  shoulder-joint  is  restricted. 

All  the  foregoing  symptoms  are  almost  identical  with 
those  seen  in  cases  of  healed  fracture  of  the  sternal  end 
of  the  clavicle. 

The  symptoms  consequent  upon  upward  dislocation 
of  the  sternal  extremity  of  the  clavicle  in  cases  in  which 
reduction  is  practised  are  usually  as  follows  :  The  inner 
extremity  of  the  clavicle  is  sliglitly  displaced  forward  or 
upward,  wliile  the  acromial  end  of  tlie  bone  is  directed 
backward,  and  is  at  the  same  time  either  slightly  raised  or 
depressed.  The  head  is  somewhat  inclined  to  tlie  injured 
side.  The  other  symptoms  of  atrophy  and  diminished 
mol)ility  arc  similar  to  those  of  the  forward  dislocation. 

Backward  displacements  give  rise  t(^  external  appear- 
ances similar  to  those  which  have  been  described.  They 
depend  chiefly  on  the  position  maintained  by  the  sternal 
extremity  of  the  bone  subsequent  to  healing.  In  almost 
all  the  cases  coming  under  my  observation  it  was  slightly 
displaced  forward,  giving  rise  to  the  symptoms  correspond- 
ing to  tliat  position.  One  patient  suffered,  in  addition, 
from  severe  neuralgic  pain  in  the  arm,  brought  on  by 
every  attempt  to  lift  tlie  arm,  and  also  from  pain  in  the 
side  of  the  neck  on  tlie  injured  side.  Another  case  was 
marked  l)y  a  rapid  ])uUe  and  attacks  of  dyspnea. 

The  treatment  should  be  directed  toward  attaining  the 
greatest  possible  degree  of  motion  in  the  shoulder-joint. 
When  passive  movements  are  ])ractise(l,  tlie  dislocated  ex- 
tremity of  the  bone  should  meanwhile  be  carefully  main- 
tained in  position.  Massage  and  electricity  are  also  useful 
in  overcoming  the  atrophy  of  the  muscles. 

The  degree  to  which  the  patient  is  incapacitated  for 
self-support  depends  on  the  loss  of  functional  ])ower  of  the 
shoulder-joint.  A  course  of  treatment  should  be  advised 
if  there  is  difficulty  in  lifting  the  arm  to  the  level  of  the 
shoulder,  or  if  this  movement   is  painful.      For  patients 


1 


DISLOCATIONS  OF  THE  CLAVICLE.  251 

who  arc  tlius  affected  an  insurance  allowance  of  from  30 '^ 
to  50^  may  be  indicated  wlien  the  riii^iit  arm  is  involved  ; 
from  20  fc  to  40  ;^  if  the  left  is  involved. 

When  the  lesion  occurs  at  the  acromial  end  of  the  clav- 
icle, the  bone  is  usually  dislocated  upward.  The  lesion 
is  produced  by  falls  on  the  shoulder,  when  the  acromial 
process  receives  the  brunt  of  the  injury,  or  by  blows  from 
objects  falling-  on  the  acromion. 

In  cases  of  partial  dislocation  in  which  the  acromio- 
clavicular ligaments  are  ])artly  torn,  the  following 
symptoms  arc  noted  :  a  slight  prominence  of  the  acromial 
extremity  of  the  clavicle ;  a  moderate  degree  of  rotation 
of  the  clavicle  on  its  long  axis  ;  atrophy  of  the  deltoid 
and  tra})ezius,  and  possibly  also  of  the  nuiscles  of  the  chest 
and  scapula  ;  pain  and  lessened  mobility  of  the  shoulder- 

The  treatment  is  symptomatic.  The  working  capacity 
of  the  patient  is  often  diminished  by  from  10^  to  20^ 
or  more. 

Complete  dislocation,  involving  complete  laceration  of 
tlie  acromioclavicular  ligaments,  is  recognized  in  the  follow- 
ing manner  :  The  acromial  extremity  is  displaced  upward 
and  is  perccptil)le  just  beneath  the  skin  ;  and  it  may  be 
separated  from  the  acromion  by  a  distance  of  2  or  3  cm. 
or  more.  It  may  be  difficult  or  impossible  to  raise  the 
arm,  especially  above  the  level  of  the  shoulder.  Move- 
ment is  likely  to  bring  the  end  of  the  clavicle  into  contact 
with  the  acromial  process,  causing  loud  crcj)itati(in  and 
pain.  The  nuiscles  are  more  ap|)reciably  atrophied  than 
in  cases  of  partial  dislocation,  and  the  condition  persists 
for  a  much  longer  time. 

Treatment. — The  effect  of  suturing  the  bone  in  posi- 
tion should  certainly  be  tried,  since  no  (»ther  method 
vields  residts  worth  mentioning.  Insurance  allowance, 
33|^  to50<;^,. 

Downward  dislocation  of  the  acromial  end  of  the 
clavicle   is  a   rare  form  (jf  injury,  produced  by  a  blow  on 


252  DISEASES  CA USED  BY  A CCIDENTS. 

the  outer  end  of  the  clavicle.  It  is  accompanied  by  ex- 
tensiv^e  laceration  of  the  ligaments,  and  in  some  instances 
by  fractnre  of  the  coracoid  process.  The  force  of  the 
l)low  may  also  be  extended  to  the  head  of  the  liumeriis, 
compressing  it  against  the  scapuUi  and  leading  possibly  to 
paretic  disturbances  from  injury  of  the  brachial  plexus. 
Tlie  joint  may  become  partly  or  totally  powerless,  move- 
ment being  regained  later  on  in  some  cases  by  gradual 
development  of  a  new  joint. 

If  reduction  can  be  maintained,  no  specially  character- 
istic symptoms  are  observed  ;  if  the  bone  remains  loose 
in  the  joint,  the  lesion  occasionally  assumes  the  appear- 
ance of  an  upward  dislocation. 

If  the  dislocation  remains  unreduced,  the  acromion  is 
seen  to  protrude  sharply,  while  the  outer  extremity  of  the 
clavicle  is  concealed  beneath  it.  The  inner  end  of  the 
clavicle  is  prominent  and  is  slightly  displaced  forward  at 
the  sternoclavicular  joint,  the  shoulder  being  somewhat 
displaced  backward.  As  a  rule,  we  find  marked  atrophy 
of  the  muscles  of  the  shoulder,  the  scapula,  the  ciiest,  and 
of  the  whole  upper  extremity,  but  especially  marked  in 
those  attached  to  the  humerus. 

Treatment. — If  stiH  unreduced,  reduction  nuist  be 
practised  under  all  circumstances;  otherwise,  passive 
movements  of  the  shoulder,   massage,  etc.,  are  indicated. 

The  degree  to  which  the  patient  is  incapacitated  depends 
on  the  loss  of  functional  [>ower, 

5.  Fractures  of  the  Scapula. 

Ainoiifi  my  cases  of  fracture  of  this  bone  the  body  of  the  ))one  was 
involved  in  19  cases  ;  the  spine  in  6  ;  the  a<Toniion  process  in  12  ;  the 
neck,  including  the  glenoid  cavity,  in  8  ;  and  the  coracoid  process  iu 
12  cases. 

In  general,  it  may  be  stated  that  fractures  of  the  scapula 
are  rare  injuries.  This  applies  especially  to  the  body  of 
the  bone,  which  is  protected  on  all  sides  by  thick  nniscles  ; 
less  so  to  its  processes ;  and  least  of  all  to  the  acromion 
process. 


FRACTURES  OF  THE  SCAPULA.  253 

(a)  Fractures  of  the  body  are  due  to  falls  on  the 
back,  to  blows  from  falling  objects,  etc.  The  lesion  is 
frequently  coni])licated  by  fracture  of  the  spine  of  the 
scapula,  and  still  iiiore  frequently  by  fractures  of  the  ribs. 
Occasionally,  the  lung  is  lacerated. 

Symptoms  after  healing  are  not  well  marked  ;  defor- 
mities are  sometimes  perceptil>le  in  thin  individuals,  but 
are  difficult  or  impossible  to  determine  in  muscular  or 
stout  patients. 

The  muscles  connected  with  the  scapula  and  the  adij)Ose 
tissue  protecting  it  undergo  more  or  less  atrophy,  the  pro- 
cess being  frequently  extended  to  the  trapezius,  supra- 
spinatus,  and  deltoid. 

The  inferior  angle  of  the  scapula  is  frequently  dis- 
placed, and  in  case  of  transverse  fractures  it  is  usually 
displaced  outward. 

When  both  arms  are  elevated  to  the  level  of  the  shoul- 
der, atrophy  of  the  teres  minor,  teres  major,  and  latissimus 
dorsi  becomes  apparent  in  the  majority  of  cases.  If  the 
fracture  involves  the  inner  superior  angle  of  the  bone,  this 
is  sometimes  drawn  upward  by  the  levator  anguli  scapulae. 
A  fracture  of  the  spine  in  a  vertical  line  can  occasionally 
be  recognized  by  callus  or  by  a  convex  nick  in  the  bone. 
Functional  power  is  but  very  slightly  affected,  although 
in  some  cases  treatment  is  required  on  account  of  restricted 
mobility  of  the  shoulder-joint. 

(b)  Fractures  of  the  acromion  are  met  with  more 
frequently,  and  in  almost  all  cases  are  due  to  direct  vio- 
lence, such  as  falls  on  the  shoulder  or  blows  from  falling 
objects.  Occasionally,  they  are  indirectly  caused  by  falls 
on  the  elbow,  and  in  rare  instances  directly  by  muscular 
action  alone.  When  due  to  direct  violence,  the  fracture  is 
usually  seated  near  the  apex  of  the  acromion,  whereas 
when  the  violence  is  indirect,  it  approaches  its  base. 

After  union  takes  place  the  apex  of  the  acromion 
appears  sharply  defined,  and  the  supra-acromial  bursa  is 
frequently  found  to  be  enlarged.     Symptoms  due  to  loss 


254  DISEASES  CAUSED  BY  ACCIDENTS. 

of  functional  power  are  but  slightly  marked  or  are  severe, 
depending  on  the  degree  of  displacement  of  the  fractured 
fragment.  In  some  cases  the  acromion  becomes  com- 
pletely  separated  from  the  rest  of  the  bone  and  a})proaches 
the  clavicle.  In  one  case  of  the  kind,  which  has  been 
under  my  observation  since  1895,  abduction  is  greatly 
restricted,  the  patient  still  being  unable  to  raise  his  arm 
above  an  angle  of  foi"ty-five  degrees.  The  external  ap- 
pearances in  this  case  are  identical  with  those  of  a  com- 
plete upward  dislocation  of  the  acromial  end  of  the 
clavicle. 

Treatment  is  mainly  a  question  of  the  restoration  of 
functional  jjower.  The  insurance  allowance  is  estimated 
according  to  the  functional  disability  :  in  very  light  cases 
none  is  required. 

(c)  Fractures  of  the  neck  of  the  scapula  frequently 
involve  the  articular  surface  of  the  glenoid  cavity  ;  they 
are  usuallv  caused  by  blows  or  falls  on  or  against  the 
shoulder,  on  the  outstretched  hand,  or  on  the  elbow.  The 
lesion  is  said  to  have  occurred  in  consequence  of  violent 
contraction  of  the  biceps  (short  head)  andcoracobrachialis.^ 
It  would  seem  that  the  only  possible  lesion  that  could  thus 
originate  in  this  situation  would  be  an  indirect  fracture  of 
the  surgical  neck,  since  the  muscles  in  question  contract  in 
the  direction  of  tiie  coracoid  process,  not  in  the  direction 
of  the  neck  of  the  sca})ula.  A  fracture  of  the  latter  might 
more  easily  be  explained  on  the  ground  of  violent  action 
on  the  part  of  the  triceps. 

After  recovery  the  affected  shoulder  usually  remains 
shortened,  and  the  head  is  sometimes  sligiitly  iucliiicd  to 
that  side  ;  the  acroiuioclavicidar  joint  is  sharply  ])romiucut, 
and  the  head  of  the  humerus  is  lowered  in  position.  If 
the  line  of  fracture  runs  across  the  glenoid  cavity,  the 
mobility  of  the  shoulder-joint  remains  restricted  for  a  long 
time,  if  not   peruianently.     The   nuiscles   coimccted   with 

1  Hoffa,  "Luxat.  ii.  Fract.,"  3d  ed.,  p.  190. 


256  DISEASES  CAUSED  BY  ACCIDENTS. 

the  shoulder  and  arm  become  greatly  atrophied,  especially 
the  long  head  of  the  triceps.  Atrophy  of  the  deltoid  may 
also  occur  in  consequence  of  paralysis  of  the  circumflex 
nerve. 

The  treatment  consists  in  exercises  of  the  shoulder- 
joint,  etc.  The  insurance  allowance  depends  on  the  power 
of  the  patient  to  raise  and  use  his  arm  ;  even  as  much  as 
75^  may  be  granted. 

Ccise  of  fracture  of  the  neck  of  the  rirjht  scapula,  due  to  a  fall  into  a  cel- 
lar, leading  to  extendve  adhesions  and  functiomd  disorders. 

A  workman,  thirty-eifiht  years  of  age,  fell  into  a  cellar  on  June  30, 
1894,  striking  on  his  right  shoulder.  He  was  treated  at  first  at  home  ; 
subsequently  in  the  hospital,  where,  between  August,  1^94,  and  Janu- 
ary, 1895,  the  adhesions  in  the  joint  were  forcibly  broken  four  times 
under  anesthesia.  The  i)atient  entered  my  hospital  on  March  1,  1895. 
He  was  rather  tall  and  of  vigorous  build.  The  right  slioulder  was 
shortened  and  slightly  rotated  inward  ;  the  muscles  of  the  right  side 
of  the  chest,  the  slioulder,  and  the  arm  were  greatly  atrophied,  those 
of  the  hand  being  also  affected.  The  arm  could  not  be  raised  at  the 
shoulder-joint  above  an  angle  of  eighty-tive  degrees,  and  movement  Avas 
painful.  The  patient  was  discharged  May  22,  1895,  with  an  allowance 
of  50%,  no  essential  improvement  having  been  eifected. 

(d)  Fractures  of  the  coracoid  process  are  usually  seen 
in  connection  with  fractures  of  the  acromion,  the  spine,  or 
the  neck  of  the  scapula  ;  with  fractures  or  dislocations  of 
the  clavicle  or  the  humerus  ;  or  with  fractures  of  the  ribs. 
Less  frequently  they  are  caused  by  muscular  contraction. 
The  lesion  is  occasionally  produced  during  the  process  of 
reduction  of  a  dislocation  of  the  humerus,  but  the  most 
frequent  cause  is  a  fall  on  the  shoulder.  If  healing 
occurs  without  displacement,  functional  power  is  satisfac- 
torily restored.  On  the  other  lian<l,  if  the  coracoid  pro- 
cess becomes  displaced  outward,  as  occurs  in  most  cases  in 
conse(|uence  of  the  action  of  the  coracobracliialis  and 
biceps  and  of  movements  of  the  arm,  it  greatly  interferes 
with  movement  of  the  shoulder-joint,  the  head  of  the 
humerus  coming  in  ciontacit  with  the  process  as  so(jn  as  the 
arm  is  slightly  raised. 

Other  symptoms  are  as  follows  :  the  groove  of  Mohren- 
heim  appears  flattened  ;  the  coracoid  process  is  displaced 


FRACTURE  OF  CORACOID  PROCESS.  257 

and  sensitive  to  pressure  at  first;  the  displacement  and 
the  callus  together  cause  it  to  feel  enlarged  and  thickened. 
The  clavicle  and  scapula  may  also  be  slightly  displaced  ; 
the  biceps  (short  head),  coracobrachialis,  and  pectoralis 
minor  invarialjly  show  signs  of  atroj)hy,  which  secondarily 
involves  the  pectoralis  major  as  well.  In  severe  cases  the 
injury  leads  to  paralysis  of  the  brachial  plexus. 

The  treatment  c<msists  in  mechanical  exercises  of  the 
shoulder-joint,  in  massage,  and  in  the  use  of  electricity. 
Operation  is  indicated  for  cases  in  which  movement  of  the 
head  of  the  humerus  is  mechanically  prevented.  The 
incapacity  for  self-support  depends  on  the  loss  of  func- 
tional ]K)wer.  On  an  average,  it  equals  30  ^  ;  for  com- 
plete ankylosis  of  the  shoulder-joint  about  75  ^/o  insurance 
is  alhjwed. 

Case  of  fracture  of  the  coracoid  process  caused  by  distoeation  of  the 
humerus.      (Fig.  28.) 

A  workman,  thirty-six  years  of  age,  addicted  to  drink,  on  August 
3,  1896,  fell  into  a  cellar  while  drunk.  He  was  treated  in  the  hos- 
pital, reduction  being  practised  immediately.  He  was  discharged  six 
weeks  later.  I  examined  him  Septeml)er  17,  1896.  He  was  of  medium 
height  and  vigorous  build.  The  groo\  e  of  Mohrenheim  on  the  right 
side  was  flattened  and  filled  out.  Tlie  right  shoulder  was  somewhat 
depres-sed.  On  palpation  the  right  coracoid  process  could  be  felt 
thickened  and  displaced  outward.  ( )n  both  active  and  passive  motion 
elevation  of  the  right  arm  was  limited  to  an  angle  of  sixty-five  de- 
grees. He  was  treated  in  my  hospital  until  April  27,  lf^97,  and  dis- 
charged practically  unimproved.  He  was  allowed  oO%  insurance, 
which  was  later  raised  by  legal  process  to  66f  % . 

The  skiagraph  (Fig.  28)  ^•ery  clearly  shows  the  displacement  of  the 
coracr)id  process  upward  and  outward.  It  is  evident  that  the  head  of 
the  humerus  must  strike  it  on  abduction.  The  muscles  arising  from 
the  coracoid  jirocess,  tlie  coracobrachialis,  and  short  head  of  the 
biceps  show  corresponding  displacement,  and  the  muscles  of  the  whole 
arm  are  markedly  atrophied. 

6.  Dislocations  of  the  ShouIder=joint. 

The  following  chapter  is  based  on  seventy-one  cases  of  this  lesion 
occurring  in  my  own  pnxctice. 

Dislocation  of  tlic  shoulder-joint  is  a  common  form  of 
injury,  occurring  in  about  50^  of  all  cases  of  dislocation. 
17 


258  DISEASES  CAUSED  BY  ACCIDENTS. 

Of  the  several  varieties  of  tlie  lesion,  the  subcoracoid  is 
most  frequently  met  with.  It  is  due  to  either  direct  or 
indirect  violence,  including  muscular  action.  It  may  be 
caused  by  a  variety  of  accidents  :  by  falling  on  the  out- 
stretched hand  or  tlie  elbow  ;  by  violently  catching  at  a 
support  when  falling  over  backward  ;  by  severe  blows, 
kicks,  or  falls  upon  or  against  the  shoulder ;  or  by  violent 
movements  of  the  arm  in  throwing,  beating,  etc. 

After  successful  reduction  recovery  sometimes  takes 
place  rapidly  and  completely,  but  in  other  cases  the  results 
are  less  favorable,  functional  disorders  remaining  that 
require  a  long  course  of  treatment,  especially  if  complica- 
tions are  present.  It  must  be  stated,  indeed,  that  the  im- 
portance of  the  consequences  of  shoulder-dislocations  is 
very  frequently  underrated. 

After  reduction  and  subsidence  of  the  swelling  the  fol- 
lowing symptoms  can  usually  be  observed  :  The  injured 
slioulder  appears  atrophied,  the  acromion  being  sharply 
defined.  Occasionally  the  deltoid  is  so  greatly  atrophied 
as  to  leave  a  deep  hollow  under  the  acromion.  The 
muscles  of  the  arm  are  invariably  atrophied  :  if  the  dis- 
location is  complicated  by  jiaralysis  of  the  nerve  plexuses, 
the  atrophy  involves,  in  addition,  the  nuiscles  of  the  fore- 
arm and  hand,  and  also  those  of  tlie  cliest,  the  neck  and 
throat,  the  scapula,  and  even  the  back  on  the  affected  side. 
This  may  result  in  the  development  of  scoliosis.  As  a 
rule,  the  arm  is  found  to  be  rotated  inward  to  a  moderate 
degree,  the  position  being  most  <'learly  shown  "when  the 
arms  are  placed  on  a  level  with  the  shoulder,  the  thumbs 
pointing  upward.  (Compare  Fig.  29.)  The  pronation  of 
the  humerus  involves  a  corresponding  displacement  of  the 
biceps  and  of  the  whole  shoulder,  the  latter  also  ajipearing 
shortened.  The  rotation  of  the  humerus  and  shoidder 
probably  depends  on  cicatricial  contractions  of  the  joint- 
capsule,  and  since  it  is  most  often  in  the  subcoracoid  form 
of  dislocation  that  the  anterior  part  of  the  cajisule  is  lacer- 
ated, we  usually  find  an  inward  rotation  in  these  cases. 


DISLOCATION  OF  THE  SHOULDER-JOINT. 


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260  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  18. 

Case  of  Reduced  Dislocation  of  the  Right  Shoulder=joint. 

Sequt4s,  extensive  adhesions  in  the  shoulder-joint,  i)aralysis  o:  tlie 
bnichial  plexus,  progressive  muscular  atrophy,  and  scoliosis. 

A  coachman,  twenty -one  years  of  age,  fell  from  a  carriage  on  Octo- 
ber 29,  1H91,  thereby  dislocating  the  right  shoulder.  He  was  treated 
in  the  hospital  until  November  21,  1891;  he  then,  on  several  occasions, 
attempted  to  \\ork,  but  was  obliged  to  discontinue. 

I  examined  him  February  9,  1892.  He  was  a  rather  small  man  ; 
the  right  shoulder  and  right  arm,  and  in  part  his  forearJii,  were 
extremely  atrophied.  Abduction  was  almost  impossil)le.  The  mus- 
cles in  part  sh()\\ed  the  reaction  of  degeneration.  He  \\as  treated  at 
my  hospital  until  July  1st,  when  he  was  discharged  for  misbehavior. 
His  condition  had  not  im])roved  ;  on  the  contrary,  there  was  a  pro- 
gressive muscular  atroiihy  that  finally  extended  over  the  whole  right 
side  of  the  chest  and  )>ack.  The  muscles  of  the  forearm  were  only 
slightly  affected,  so  that  the  hand  remained  useful.  He  was  allowed 
40^  insurance. 

The  arm  could  be  raised  (at  the  shoulder-joint)  only  to  an  angle  of 
thirty-five  degrees.  The  circumference  of  the  affected  arm  measured 
less  than  that  of  the  other,  as  follows  :  at  its  lower  third,  4  cm.  less  ; 
at  the  middle  of  the  biceps,  (!  cm.  less  ;  at  the  axilla,  7  cm.  less  ;  at 
the  forearm  near  the  elbo\\',  nearly  2  cm.  less. 

Tuberculosis  of  the  lungs  was  diagnosed  in  August,  1895,  and  the 
patient  died  one  year  later. 

Altliouo'li  in  some  cases  the  direction  of  rotation  is  not 
clearly  niai'ked,  there  may  nevertheless  l)e  evidence  of 
adhesions  and  cicatricial  contractions  dne  to  the  lacera- 
tion of  ligaments,  tendons,  or  muscles,  or  to  the  chip- 
pin(>;-oif  of  bits  of  cartilage  or  bone.  It  is  to  complications 
of  this  nature  that  ankylosis  is  often  to  be  ascribed.  Some- 
times when  there  is  no  ])aralysis  movement  may  be  greatly 
restricted,  so  that  it  is  hardly  possible  to  raise  the  arm  to 
a  level  with  the  shoulder,  even  with  the  cooperation  of 
the  scapula.  Secondary  contractures  of  the  elbow-joint 
are  also  sometimes  observed. 

When  bits  of  cartilage  or  bone  are  broken  off,  the  cal- 
lus that  subsecjuently  forms  may  lead  to  complete  anky- 
losis of  the  shoulder-joint.  Fracture  of  structures  within 
or  connected  with  the  joint  may  occur  at  the  time  of 
injury,  or  during  the  process  of  reduction.      In  this  way 


t>> 


/ 


K 


DISLOCATIONS  OF  THE  SHOULDER.  261 

the  coracoid  process,  the  greater  tuberosity,  and,  less  fre- 
quently, the  lesser  tuberosity  may  be  broken  off,  or  the 
humerus  may  be  fractured  at  its  anatomic  neck,  or  occa- 
sionally at  its  surgical  neck. 

The  paralyses,  which  are  very  frequent  sequels  to  dis- 
locations of  the  shoulder-joint,  may  depend  on  direct 
laceration  of  the  circumflex  nerve  or  on  injuries  to  the 
brachial  plexus.  Usually  the  latter  is  only  partly  in- 
volved. Paralysis  of  the  ulnar  nerve  occasionally  occurs 
as  a  late  symptom,  leading  to  claw-hand  and  to  tropho- 
neurotic disorders.  The  effects  of  the  paralysis  are  motor 
and  sensory.  Among  the  sensory  symptoms  are  disturb- 
ances of  the  temperature-sense,  subjective  coldness,  formi- 
cation, etc.  Electric  irritability  may  be  only  depressed 
or  the  reaction  of  degeneration  may  be  present.  In  severe 
cases  edema  and  cyanosis  of  the  arm  are  also  observed. 
Pronounced  loss  of  power  in  the  hand  is  the  rule,  although 
in  some  cases  of  severe  plexus-injury  considerable  strength 
is  retained. 

The  prognosis  as  to  function  after  recovery  from  dis- 
locations attended  by  complications  of  the  kind  just  de- 
scribed is  unfavorable  in  tlie  majority  of  cases.  Very 
few  patients  can  be  discharged  completely  cured.  The 
prognosis  depends  also  on  the  age  of  the  patient,  be- 
coming less  favorable  with  advanciup;  years.  A  certain 
amount  of  improvement  may,  however,  gradually  take 
place  in  the  course  of  years,  both  as  regards  paralysis 
and  ankylosis.  1  In  case  of  the  latter,  improvement  is 
sometimes  due  to  the  formation  of  a  new  joint. 
.  Although  treatment  may  in  some  severe  cases  prove 
entirely  unsuccessful,  its  value  should  not  for  that  reason 
be  underrated,  since  in  the  great  majority  of  cases  much 
can  be  accomplished  by  means  of  systematic  massage, 
baths,  medicomechanical  exercises,  and  electricity.  This 
demands  much  patience  on  the  part  of  both  doctor  and 

1  In  the  strict  sense  of  the  word,  it  is  incorrect  to  speak  of  "anky- 
losis "  in  describing  all  forms  of  stiffness  of  a  joint. 


262  DISEASES  CA USED  BY  A CCI DENTS. 

patient,  as  recovery  is  usually  a  very  slow  process.  In 
severe  cases  the  course  of  treatment  may  cover  a  year  or 
more. 

The  insurance  allowance  is  proportionate  to  the  loss  of 
functional  power,  and  may  be  as  high  as  75^. 

Subspinous  dislocations  are  of  comparatively  rare  occur- 
rence ;  they  are  usually  caused  by  a  fall  on  the  hand  or 
elbow  when  the  arm  is  directed  forward  and  at  the  same 
time  strongly  abducted. 

The  symptoms  subsequent  to  reduction  differ  in  nowise 
from  those  of  the  subcoracoid  variety,  except,  possibly,  in 
respect  to  the  position  of  the  arm  and  shoulder.  Tlie 
complications  of  the  two  varieties  are  also  identical. 

Old  unreduced  dislocations  are  seldom  met  with  in  acci- 
dent-practice. Even  in  these  cases  reduction  should  be 
attempted ;  otherwise,  treatment  and  prognosis  are  the 
same  as  for  ankylosis  of  the  shoulder  in  general. 

Sometimes  dislocation  of  the  shoulder-joint  leads  to  a 
condition  of  recurrent  or  habitual  dislocation  ;  the  head  of 
the  humerus  is  likely  to  slip  out  of  the  glenoid  cavity  on 
the  slightest  provocation,  and  it  becomes  necessary  for  the 
patient  to  W(^ar  a  fixation-bandage  in  order  to  perform 
even  light  tasks,  heavy  work  being  quite  out  of  the  ques- 
tion. Fixation  by  suture,  according  to  Ricard,  is  to  be 
recommended.  These  cases  require  a  high  rate  of  insur- 
ance allowance. 

Fractures  of  the  shoulder-joint  have  already  been 
referred  to  in  one  instanc(! — that  of  fracture  of  the  glenoid 
cavity.  Fracttu'cs  of  the  articular  portion  of  the  head  of 
the  humerus  will  be  discussed  in  connection  with  lesions 
of  the  arm. 

Cfl.se  of  (litilncation  of  the  rif/lil  sJiouldcr-joinf,  in  irhich  rcducfion  was 
practised.     Sequel,  severe  perinauent  paralysis  of  tlie  brachial  )»lexus. 

A  stone-mason,  twenty-seven  years  of  age,  was  injurt'd  hy  the  cav- 
ing-in  of  a  building  on  April  8,  1891.  He  sustained  a  dislocation  of 
the  shoulder-joint  and  direct  fractures  of  several  ribs,  the  latter  lesion 
being  followed  later  on  by  tuberculosis.  I  examined  him  July  7,  1891. 
The  right  arm  hung  limp  at  his  side,  and  his  right  shoulder  was  de- 


TRAUMATIC  SYNOVITIS  OF  THE  SHOULDER.       263 

pressed.  From  the  elbow  do^vni  to  the  ends  of  the  fingers  there  were 
edema  and  cyanosis.  There  was  marked  subjective  coklness  of  the 
part.  Active  movement  of  the  shonkler-joint  was  out  of  the  ques- 
tion ;  the  mobility  of  the  elbow-joint  was  comparatively  well  pre- 
served. The  right  hand  could  be  closed  with  some  difficulty  and  could 
exercise  no  pressure  whatever.  The  muscles  of  the  right  side  of  the 
chest,  neck,  and  Ijack  were  greatly  atrophied.  The  reaction  of  degen- 
eration was  present.     Insurance  allowance,  100%. 

Thirty-nine  cases  of  healed  fracture  of  the  shoulder-joint  occurring 
in  my  own  practice  have  been  utilized  in  the  preparation  of  the  fore- 
going description. 

Traumatic  Synovitis  of  the  Shoulder=joint. 

Acute  traumatic  synovitis  of  the  shoulder-joint  develops 
after  contusions,  sprains,  dislocations,  and  fractures. 

The  symptoms  are  swelling,  fever,  and  functional  dis- 
ability. 

The  treatment  consists  of  putting  the  part  at  rest, 
either  by  ordering  the  patient  to  remain  in  bed  or  by  the 
use  of  a  bandage  ;  also  in  the  employment  of  antiphlogis- 
tic measures  and,  later  on,  in  massage  and  movements  of 
the  joint. 

Chronic  synovitis  is  a  sequel  to  the  acute  form.  The 
absorption  of  the  exudate  is  followed  by  proliferation  and 
hypertrophy  of  the  synovial  folds  ;  adhesions  form  between 
the  latter,  and,  if  the  capsule  was  lacerated  by  the  injury, 
it  becomes  involved  in  cicatricial  contractions.  The 
muscles  and  the  parts  of  the  bones  concerned  in  the  move- 
ments of  the  shonkler-joint  all  undergo  atrophy.  Move- 
ment is  restricted,  and  on  passive  motion  cracking  sounds 
are  both  heard  and  felt  in  the  joint.  The  condition  is,  as 
a  rule,  only  slightly  painful.  The  average  insurance 
allowance  is  from  20^  to  25^. 

Tuberculous  synovitis  of  the  shoulder-joint  develops  after 
traumatism,  usually  after  a  contusion  or  dislocation  ;  it 
occurs  comparatively  often  in  young  people.  The  acute 
synovitis  is  succeeded  by  a  purulent  epiphysitis,  accom- 
panied by  fever  ;  fistulas  subsequently  develop  and  seques- 
tra are  thrown  off.  The  treatment  is  purely  surgical,  and 
it  may  be  necessary  to  continue  it  for  a  number  of  years. 


264  DISEASES  CAUSED  BY  ACCIDENTS. 

The  fistulas  constantly  break  open  again,  and  new  ones  form 
in  consequence  of  metastatic  growth,  causing  rejx'ated 
attacks  of  fever  and  requiring  frequent  operations.  When 
healing  finally  takes  place,  the  part  remains  deeply  scarred  ; 
the  unfavorable  effects  of  the  scar-tissue  may,  however,  be- 
come modified  in  time.  The  arm  remains  undersized.  In 
some  cases  the  tuberculous  process  develops  very  slowly 
and  insidiously,  so  that  years  may  elapse  before  suppura- 
tion sets  in. 

As  contractures  and  ankylosis  of  the  shoulder-joint  have 
already  been  referred  to  a  number  of  times,  it  would  be 
superfluous  to  discuss  them  here. 

Loose-jointedness  was  mentioned  in  connection  with 
recurrent  dislocation. 


2.  INJURIES  OF  THE  ARM. 

The  total  niiniber  of  injuries  of  the  arm  coming  under  my  oliserva- 
tioii  was  167;  this  number  was  made  up  as  follows  :  24  cases  of  contu- 
sion, with  or  without  accompanying  wounds;  5  cases  of  muscle  strain; 
8  of  subcutiineous  rupture;  54  fractures;  71  dislocations  of  the 
shoulder-joint;  2  wounds  caused  by  bites ;  2  punctured  wounds.  The 
right  arm  was  involved  alone  in  94  cases,  the  left  in  72  cases;  in  one 
case  both  arms  were  injured. 

I.  Contusions  of  the  Arm. 

Slight  contusions  caused  l)y  blows,  kicks,  or  falls  usually 
heal  quickly  and  completely.  On  the  other  hand,  when 
the  arm  is  severely  crushed,  as  in  accidents  due  to  cav- 
ings-in,  etc.,  recovery  is  slow.  In  such  cases  the  soft 
parts — the  skin,  fascise,  muscles,  vessels, and  nerves — are  all 
more  or  less  crushed  and  torn.  Extensive  laceration  of 
the  muscles  leads  to  atrophy  and  loss  of  functional  power, 
while  the  injured  nerves  remain  inflamed  (neuriti.s)  or 
paralyzed  for  a  long  time. 

2.  Wounds  of  the  Arm. 

Simple  lacerated  or  punctured  wounds,  unless  followed 
by  cellulitis,  are  of  little  importance.     Wounds  of  large 


WOUNDS  OF  THE  ABM.  265 

size  lead  to  cicatrices  that,  if  deeply  attached  or  much 
retracted,  interfere  with  the  functional  action  of  the  part. 
Deep  wounds  of  the  axilla  are  especially  dangerous,  and 
the  resulting  cicatrices  are  likely  to  prevent  free  abduction 
of  the  arm.  Extensive  scars  on  the  posterior  surface  of 
the  arm  may  similarly  restrict  the  action  of  the  elbow- 
joint. 

Wounds  caused  by  bites  are  serious  injuries,  not  only 
because  of  the  irregularity  of  the  wound  and  the  danger 
of  infection,  but  also  because  they  are  likely  to  lead  to 
unfavorable  conditions  of  the  injured  parts  of  the  skin 
and  muscles,  and  to  paralysis  of  the  nerves  involved.  In 
one  patient  of  mine,  a  coachman,  who  was  bitten  by  a 
horse,  there  was  paralysis  of  the  radial  and  median 
nerves  requiring  a  long  course  of  treatment. 

The  muscles  of  the  arm  are  occasionally  ruptured  sub- 
cutaneously,  the  long  head  of  the  biceps  being  most  fre- 
quently involved. 

Eight  such  cases  liave  come  under  my  observation.  Only  in  one,  in 
which  the  tendon  of  the  biceps  was  completely  torn  through  at  a  point 
in  its  passage  through  the  shoulder-joint,  was  the  injury  followed  by 
severe  symptoms  of  functional  disability.  The  patient  in  this  case 
was  a  workman,  forty-eight  years  of  age,  who,  in  breaking  tlu-ough  a 
scaffolding,  had  clung  to  it  with  his  right  arm.  The  strength  of  the 
arm  was  considerably  dinninished  ;  he  was  unable  to  raise  it  with  the 
usual  degree  of  force,  and  flexion  at  the  elbow-joint,  and  more  par- 
ticularly supination,  were  much  restricted.  The  lesion  in  the  remain- 
ing cases  was  caused  by  falls  from  a  height ;  one  patient  had  fallen 
with  outstretched  arms  into  a  box  of  lime.  "\Mien  I  examined  these 
patients  at  the  end  of  the  thirteenth  week,  I  found  comparatively  few 
symptoms  of  functional  disability. 

If  the  long  head  of  the  biceps  is  only  partly  torn 
across,  tlie  symptoms  of  functional  disability  frequently 
disappear  soon  afterward.  I  have  discovered  partial  rup- 
tures of  this  kind  when  examining  workmen  for  other 
reasons  ;  some  of  the  patients  dimly  remembered  having 
suffered  from  a  slight  sprain  years  iK'fore,  while  others 
were  unable  to  give  any  explanation  of  the  lesion. 

Subcutaneous   ruptures  of  the  biceps  present  a  very 


266  DISEASES   CAUSED  BY  ACCIDENTS. 


PLATE   19. 

Case  of  Partial  Rupture  of  the  Long  Head  of  the  Biceps  on 
the  Right  Side,  Leading  to  Slight  Functional  Disability. 

A  workman,  forty  yearn  of  ajje,  fell  clown  stairs  on  April  30,  1898, 
striking  on  his  right  shoulder.  He  continued  working,  but  complained 
of  pain  in  the  shoulder.  The  physician  whom  he  consulted  i)rescribed 
inunctions  ;  subsequently  he  stopped  w'ork  and  was  placed  on  the  sick- 
list.  I  examined  him  on  October  20,  1898.  The  accompanying  illus- 
tration shows  the  two  arms  placed  in  a  similar  position.  When  the 
right  arm  is  compared  with  the  left,  its  outline  is  seen  to  be  defective 
at  a  point  corresponding  to  the  long  head  of  the  biceps.  The  ball-like 
mass  to  which  the  nuiscle  had  contracted  is  Ijetter  shown  in  the 
posterior  view.  Flexion  and  sui)iuation  were  both  interfered  with  in 
the  right  arm.  This  case  was  not  brought  up  for  decision  as  to  insur- 
ance allowance. 

characteristic  appearance  ;  on  contraction  the  muscle  curls 
n\)  into  a  round  ball,  beside  which  the  line  of  rupture 
can  be  easily  traced.     (Compare  with  Phite  19.) 

In  addition,  the  following  symptoms  are  presented : 
noticeable  atrophy  of  the  bicei)s  and  triceps  ;  atro])hy  of 
the  suj)inators  of  the  forearm  ;  diminished  power  of  flex- 
ion and  supination  of  the  elbow-joint ;  and  general  weak- 
ness of  the  arm. 

I  have  seen  two  cases  of  ])artial  rupture  of  the  short 
head  of  the  biceps  due  to  violent  movements  of  the  arm 
in  pulling. 

The  triceps  is  sometimes  ruptured  by  falls  on  the  arm 
when  tlie  latter  is  flexed.  Occasionally,  the  muscle  and 
tendon  escape  and  tlie  olecranon  process  is  torn  off  instead. 
If  after  complete  rupture  the  triceps  tendon  is  not  re- 
united by  suture,  the  nuiscle  rapidly  undergoes  atrophy. 
This  leads  secondarily  to  atropliy  of  the  flexors.  The  arm 
loses  in  strength  ;  the  power  of  extending  tlie  forearm  is 
diminished,  if  not  entirely  suspended. 

Extensive  scars  arising  from  burns,  if  they  encircle  the 
shoulder  or  elbow  or  are  deeply  attached,  are  likely  to 
limit  the  mobility  of  the  arm  by  causing  abnormal  tension 
of  the  skin  over  the  joint. 


^  .J 


FRACTURES  OF  THE  HUMERUS.  267 

3.  Fractures  of  the  Humerus. 

Fractures  of  the  Head  of  the  Humerus. — 

Fractures  of  the  head  of  the  humerus  occurring  as  the  sole  lesion 
are  a  rare  form  of  fracture.  Nine  such  cases  have,  however,  come 
under  my  observation.  In  one  case  the  greater  tuberosity  was  also  in- 
volved, the  line  of  fracture  passing  through  the  anatomic  neck.  I 
liave  also  seen  nine  cases  of  fracture  of  the  surgical  neck.  In  almost 
all  these  cases  the  lesicjn  was  caused  by  a  fall  from  a  height  ( ladder, 
window,  or  stairway).  One  patient  was  thrown  from  a  wagon; 
another,  a  hod-c-arrier,  was  injured  by  a  hod  tilled  with  Ijricks  falling 
on  his  outstretched  arm.  In  another  case  the  fracture  was  produced 
during  the  reduction  of  a  dislocation  of  the  shoulder-joint. 

Fractures  of  the  head  of  the  humerus  or  of  its  anatomic 
neck  usually  lead  to  serious  functional  di.sability.  Either 
the  head  of  the  bone  is  torn  oif  at  its  anatomic  neck  by 
indirect  violence,  or  the  tuberosities  are  similarly  affected  ; 
or,  in  case  of  direct  fractures,  the  lesion  is  often  com- 
plicated by  a  fracture  of  the  coracoid  process,  the  gle- 
noid cavity,  or  the  neck  of  the  scapula.  The  force  of 
the  fall  or  blow  on  the  shoulder  that  is  sufficiently  severe 
to  fracture  the  head  of  the  humerus  is  very  likely  to  ex- 
tend to  the  adjacent  bones.  Fractures  of  the  head  of  the 
humerus  are,  therefore,  likely  tt)  be  followed  by  the  growth 
of  .strong  adhesions  within  the  joint,  which  are  very 
difficult  to  overcome.  The  condition  may  be  relieved,  to  a 
certain  degree,  by  early  employment  of  massage  and  pas- 
sive movements.  As  in  most  cases  of  injury,  the  best 
residts  are  obtained  in  youthful  patients ;  recovery  is  less 
and  less  to  be  hoped  for  the  greater  the  age  of  the  patient. 
The  same  is  true  of  separation  of  the  epiphysis  accom- 
panied by  marko<l  displacement.  Even  in  case  of  uncom- 
plicated fractures  of  the  head  of  the  humerus  the  functional 
power  of  the  joint  is  likely  to  remain  seriously  impaired, 
for  the  simple  reason  that  it  is  the  joint  itself  that  is 
involved. 

In  one  c^iseof  separation  of  the  upper  epiphysis  of  the  left  humerus, 
in  A\  hich  the  upper  fragment  was  displaced  backward,  while  the  lower 
fragment  was  displaced  considerably  forward,  the  patient,  a  boy  of  six- 


268  DISEASES  CAUSED  BY  ACCIDENTS. 

teen,  -vvas  able,  two  months  after  the  injury,  to  raise  his  arm  to  an 
angle  of  eighty-five  degrees,  although  one  month  earlier  his  shoulder 
had  Ijeen  completely  ankylosed. 

The  following  symptoms  of  fracture  of  the  head  of  the 
humerus  are  observed  after  recovery  :  the  shoulder  is  per- 
ceptibly thickened,  especially  as  seen  from  the  side ;  it  is 
in  some  cases  elevated,  in  others  depressed,  in  comparison 
with  the  opposite  shoulder.  The  groove  of  INIohrenheini 
is  filled  out.  The  deformity  of  the  head  of  the  humerus 
can  usually  be  felt  through  the  soft  parts.  The  arm  fre- 
quently appears  shortened  and  is  sometimes  held  a1)ducted, 
while  the  muscles  of  the  shoulder,  neck,  and  arm,  and 
frequently  also  those  of  the  forearm  and  hand,  show 
signs  of  atrophy.  Abduction  is  limited  ;  in  many  cases 
even  after  from  three  to  six  months  of  systematic  treat- 
ment, counting  from  the  date  of  accident,  the  arm  can 
barely  be  raised  to  an  angle  of  from  sixty  to  seventy  de- 
grees. When  extensive  adhesions  have  formed,  abduction 
above  ninety  degrees  is  often  impossil)le,  even  a  number 
of  years  later,  and  then  is  accom[)lished  only  with  the 
cooperation  of  the  whole  shoulder  and  with  considerable 
effort  on  the  part  of  the  patient.  It  is  usually  easier  to 
raise  the  arm  anteriorly.  Backward  movement  and  rota- 
tion are  also  restricted,  and  the  whole  extremity  become 
weak.  The  long  teudon  of  the  bit!eps  rarely  escapes 
injury  when  the  head  of  the  humerus  is  fractured.  It  is 
also  frequently  involved  in  the  adhesions  that  subse(|uently 
form.  Consequently,  contractures  of  the  elbow-joint  are 
often  observed  in  these  cases.  The  tendon  is  also  occa- 
sionally displaced  from  its  groove.  Other  sequels  occur 
in  the  shape  of  ])aralysis  and  circulatory  disorders,  Avhich 
may  be  due  to  direct  injury  of  nerves  and  vessels  or  to 
pressure  from  callus. 

Case  of  fracture  of  the  head  of  the  rif/ht  humerus,  near  the  anatomic 
neck.     (Fig.  30.)     Result,  serious  functional  disability. 

A  man,  forty-two  years  of  age,  fell  about  seventeen  feet,  on  October 
27,  1897.  He"  was  treated  in  the  liospital  until  January  3,  1898.  I 
examined  him  January  4,  1898.     He  A\as  a  large,  strong  man.     The 


Fig.  30. 


270  DISEASES   CAUSED  BY  ACCIDENTS. 

riglit  shoulder  seemed  thickened,  tlie  arm  somewhat  abducted,  and 
M  ohrenheim '  s  groove  filled  out.  Tlie  coracoid  ])rocess  seemed  enlarged . 
The  muscles  over  the  chest  and  shoulder  were  atrophied.  Elevation  of 
the  arm  limited  to  (10  degrees,  ('repitation  was  ])i  esent,  and  the  limita- 
tion of  motion  was  marked.  The  i)atient  was  treated  in  my  institute 
from  January  5,  18!)S,  to  August  12,  189H.  The  iusiu'ance  allowance 
wa«  then  fixed  at  33^%.  The  arm  could  be  passively  elevated  to 
115  degrees.  The  patient  himself  could  elevate  it  to  7U  degrees,  but 
all  mo\ement  was  still  greatl}^  impaired,  lie  later  received  50% 
insurance  allowance. 

Case  of  osteomyelitis  of  the  head  of  the  humerus,  with  extension  by  metas- 
tasis to  the  left  scapula,  left  thi(jh,  and  rigid  elbow-joint,  followiny  a  severe 
contusion,  of  the  right  arm  and  right  shoulder.     Hequel,  recovery. 

A  roofer's  apprentice,  fifteen  years  of  age,  was  injured  on  October 
25,  1894,  by  the  fall  of  some  slate  on  his  right  arm  and  shoulder.  He 
continued  to  work  for  two  days  after  injury.  On  the  third  day  the 
injured  part  became  s\\()llen  and  painful  ;  the  patient  felt  fe\erisli 
and  remained  in  bed.  A  physician  was  called  on  the  fifth  day  and 
the  imtient  was  taken  to  the  hospital.  On  tlie  folloA\  ing  day  incisions 
were  made  and  pus  was  e\'acuated.  This  o])eration  was  repeated  a 
numlxn-  of  times.  A  fistula  formed  in  the  right  arm  near  tlie  del- 
toid, followed  l)y  the  development  of  a  second  iistula  above  the  spine 
of  the  left  sca])ula. 

I  examined  the  patient  August  17,  18<)5.  He  was  a  small,  poorly 
developed  boy.  There  were  a  number  of  scars  on  tlie  right  shoulder, 
which,  together  with  the  right  arm,  Avas  greatly  atroi)liieil.  A  fistula 
still  remained  over  the  left  scapula,  leading  toward  the  supraspinous 
fossa.  The  right  arm  could  ))e  only  slightly  aliducted,  and  the  right 
ell)ow-joint  was  ankylosed  at  an  angle  of  140  degrees.  I  treated  the 
patient  until  ISIarch,  1890,  when  he  was  disctiarged  with  an  insurance 
allowance  of  50%.  He  was  under  treatment  a  number  of  times  sub- 
secpiently.  At  the  end  of  1898  he  was  again  obliged  to  enter  the 
hospital  on  account  of  the  sudden  appearance  of  al)sc-csses  in  the  left 
thigh,  tiie  riglit  e!l)ow-j()int,  and  the  neck,  all  of  whii-h  were  opened. 

By  the  13th  of  May,  1H99,  all  the  fistulas  had  closed  and  the  scars 
appeared  pale  and  superficial.  The  patient  was  able  to  move  his  riglit 
arm  and  right  elbow-joint  with  ease  and  freedom,  and  could  raise  his 
arm  to  an  angle  of  175  degrees.  He  was  al)le  to  work  for  ten  hours 
daily.  The  development  of  the  right  arm,  however  was  impaired;  the 
muscles  were  all  considerably  atrophied.  The  strength  of  the  right 
hand,  nevertheless,  almost  equaled  that  of  the  left.  Insurance  allow- 
ance, 10%. 

Fractures  of  the  greater  tuberosity  arc  compara- 
tively seldom  seen  ;  the  lesion  is  clirct-tly  caused  by  falls 
or  blows,  or  it  occurs  during  dislocation  of  tlie  shoulder- 
joint  or  in  reduction  of  the  same.  It  is  only  in  rare  in- 
stances that  the  tuberosity  is  torn  oflP. 

The  symptoms  after  union  takes  place  are  as  follows  : 


FRACTURES  OF  THE  HU3IERUS.  271 

the  shoulder  is  thickened  from  before  backward  ;  fre- 
quently the  acromion,  or  the  tuberosity,  if  displaced,  is 
distinctly  prominent ;  the  nuiscles  of  the  shoulder,  chest, 
and  arm  are  atro})hied,  and  movements  of  the  arm,  espe- 
cially those  of  abduction  and  outward  rotation,  are  re- 
stricted. The  muscles  that  primarily  undergo  atrophy 
are  the  pectoralis  major,  the  supraspinatus  and  infraspi- 
natus, and  the  teres  minor ;  the  antagonists  atrophy 
secondarily.  The  action  of  the  antagonists  sometimes 
produces  a  slight  partial  dislocation  of  the  head  of  the 
humerus  in  the  form  of  an  inward  rotation. 

Case  of  fracture  of  the  right  greater  tuberoHify,  uith  eomequent  severe 
fu nctional  disability. 

A  mason,  fifty-eight  years  of  age,  fell  from  a  ladder  on  April  5,  1890, 
striking  on  his  left  shoulder.  He  was  under  my  care  from  June,  1890, 
until  May,  1893.  His  symptoms  were  as  follows  :  considerable  thick- 
ening of  the  right  shoulder,  which  a])peared  more  massive  than  the  left 
one  ;  the  muscles  of  the  right  shoulder,  chest,  and  arm  Avere  much 
atrophied,  and  the  arm  could  hardly  be  raised  at  all.  The  head  of  the 
humei'us  was  distinctly  rotated  inward.  The  insurance  allowance  at 
the  time  of  the  patient's  discharge  was  40%,  later  raised  by  legal  pro- 
cess to  60%.  At  that  time  his  arm  could  barely  be  raised  to  an  angle 
of  eighty  degrees. 

The  skiagi-aph,  which  was  taken  later,  shows  a  displacement  of  the 
entire  greater  tuberosity,  which  strikes  against  the  acromion  when  the 
arm  is  raised.  In  July,  1897,  it  could  be  raised  to  an  angle  of  a1)out 
110  degrees.     There  has  been  no  sul)sequent  imi)rovement. 

In  another  case  of  fracture  of  the  gi'eater  tuberosity  occurring  in  a 
boy  of  fifteen,  the  se])arated  tuberosity  was  displaced  inward  and  ui)- 
ward,  and  could  be  distinctly  felt  iinder  the  skin.  Six  weeks  later  the 
arm  could  be  raised  to  an  angle  of  145  degrees. 

Fractures  of  the  lesser  tuberosity  also  occur  very 
seldom  as  isolated  lesions.  The  direct  fractures  arise  from 
the  same  causes  as  those  already  enumerated  for  the  fi'ac- 
tures  of  the  greater  tuberosity. 

The  symptoms  of  fracture  of  the  lesser  tuberosity  after 
union  is  completed  are  outward  rotation  of  the  humerus 
and,  to  a  certain  extent,  of  the  shoulder  ;  atrophy  of  the 
muscles  of  the  shoulder,  cliest,  and  arm  ;  partial  disloca- 
tion of  the  shoulder-joint ;  diminished  ])owcr  of  abduction. 
The  arm  appears  thickened  in  the  region  of  the  axilla. 


272  DISEASES  CAUSED  BY  ACCIDENTS. 

Case  of  separation  of  the  lesser  tuberosity  due  to  the  aetion  of  the  sub- 
scajjularis. 

A  mason,  forty-nine  years  of  age,  was  cleaning  the  ceiling  with  his 
right  arm,  when,  in  order  to  save  liimself  from  falling  in  consequence 
of  a  misstep,  he  canght  at  the  wall  with  liis  hand.  He  immediately 
felt  pain  in  the  shoulder.  Wlien  I  examined  him,  1  found  a  small, 
irregular,  pointed  tumor  on  the  right  arm  rather  in  the  anterior  part 
of  the  axilla.  The  muscles  of  the  right  shoulder,  chest,  and  arm  were 
partially  atrophied ;  the  shoulder  was  slightly,  displaced  liackward  and 
Avas  somewhat  shortened.  Pressure  on  the  bony  tumor  in  the  axilla 
caused  the  patient  much  pain,  which  he  felt  down  to  the  ends  of  his 
fingers.  On  active  nu>tion  tlie  arm  could  he  raised  to  an  angle  of  130 
degrees;  on  passi\e  motion,  to  \r){)  degrees. 

The  skiagni])]!  showed  a  bony  tumor  situated  at  about  the  surgical 
neck  of  the  right  humerus,  while  the  lesser  tuberosity  is  absent  from 
its  normal  site;  the  head  of  the  humerus  is  somewhat  displaced  for- 
ward.    Insurance  allowance,  25%. 

Treatment. — When  tlic  greater  or  lesser  tuberosity  is 
torn  off  and  displaced,  it  may,  after  union,  be  found 
fixed  in  a  position  very  unfavorable  to  the  movement  of 
the  shoulder.  This  applies  more  especially  to  the  greater 
tuberosity,  but  in  either  case  operative  lueasures  are  in- 
dicated for  the  relief  of  the  condition.  Oi)eration  is  also 
to  be  recommended  when  the  biceps  tendon  is  cauoht  in 
the  callus  after  a  fracture  of  one  of  the  tuberosities, 
therebv  producing  ankylosis  of  the  shoulder  and  at  the 
same  time  a  contracture  of  tlie  elbow-joint. 

Separation  of  the  upper  epiphysis  of  the  humerus 
occurs  quite  frequently  up  to  the  twentieth  year  ;  less 
frequently  between  the  twentieth  and  twenty-fifth  year. 
The  lesion  is  caused  by  a  fidl  on  the  shoulder  or  out- 
stretched arm.  It  is  of  importance  chiefly  fi)r  the  reason 
that  the  development  of  the  affected  arm  is  likely  to  re- 
main j)ermanently  impaired  and  smaller  than  its  fellow, 
the  nuis(^les  ])eing  smaller  and  weaker,  and  tlie  hand  being 
usually  un<lersized. 

United  fractures  of  the  surgical  neck  are  often  fol- 
lowed by  functional  disorders,  which,  altliough  not,  as  a 
rule,  of  so  serious  a  chara(;ter  as  those  incidental  to  frac- 
ture of  the  structures  within  the  joint,  are  sufficiently 
grave  and  persistent. 


FRACTURES  OF  THE  HUMERUS.  273 

The  symptoms  are  as  follows  :  the  humerus  is  usually 
shortened,  the  shoulder  is  thickened,  and  the  groove  of 
Mohrenheim  is  filled  out.  If  the  shaft  of  the  bone  is 
displaced  inward  and  the  head  is  displaced  outward,  the 
former  will,  at  the  same  time,  be  found  abducted.  The 
long  tendon  of  the  biceps  is  usually  more  or  less  injured 
and  displaced.  As  the  brachial  plexus  lies  in  the  imme- 
diate vicinity  of  the  seat  of  fracture,  paralyses  due  to  its 
involvement  are  not  infrequent.  A\'hether  paralyzed  or 
not,  all  the  muscles  of  the  shoulder  and  arm  undergo 
atrophy,  the  muscles  of  the  forearm  being  also  affected 
to  a  certain  extent.  The  shoulder  appears  slightly  ele- 
vated or  depressed,  according  to  the  position  of  the  upj)er 
fragment  after  consolidation.  The  shaft  of  the  humerus  is 
usually  rotated  inward  by  the  pectoralis  major.  Abduc- 
tion is  almost  always  restricted  ;  in  some  cases,  however, 
this  movement,  in  the  course  of  time,  can  be  fairly  well 
executed.  If  both  arms  are  raised  together  as  nearly  to 
the  horizontal  as  the  condition  of  the  affected  shoulder 
will  permit,  the  thumbs  p(^inting  upward,  the  shoulder 
on  the  injured  side  invariably  appears  higher  than  its 
fellow  and  at  the  same  time  shortened.  The  biceps  in 
this  position  is  seen  to  be  directed  somewhat  downward,  as 
evidenced  by  the  position  of  its  tendons  in  the  axilla. 
Posteriorly,  the  olecranon  looks  somewhat  upward.  The 
dis])lacement  of  the  biceps  tendon  in  the  shoulder-joint 
and  the  rotation  of  the  shoulder-joint,  which,  as  a  ride,  is 
an  inward  rotation,  necessarily  have  an  influence  on  the 
position  of  the  elbow-joint ;  this  is  usually  slightly  pro- 
nated,  in  rare  instances  supinated,  and  is  (juite  frequently 
fixed  in  an  abnormal  ])osition  by  contractures.  Complete 
ankylosis  may  result  from  excessive  growth  of  callus, 
especially  when  the  line  of  fracture  is  irregular  and  ex- 
tends into  the  joint. 

CoKC  of  comjtdutid  frddior  of  the  riyht  hinnrrus  »<(ir  the  shduldcr-joinf, 
followed  hif  rcrorcri/  \rilh  markctl  ilcfdniiiti/  (iinl  finiclioiial  dindhiJili/. 
A  wcK'knian,  forty-seven  years  of  age,  on  August  5,  189.3,  fell  from 
18 


274  DISEASES  CAUSED  BY  ACCIDENTS. 

a  height  of  one  and  one-lialf  stones  into  a  cellar.  He  sustained 
several  wounds  of  the  face  in  addition  to  the  fractiire  pre^•iously  men- 
tioned. He  More  a  splint  for  four  weeks,  and  was  then  treated  by 
massage.  The  patient  was  in  my  care  from  October  18,  1895,  until 
the  following  August. 

The  left  shoulder  appeared  greatly  thickened  and  was  exceedingly 
prominent  on  its  outer  aspect.  The  muscles  of  the  -whole  left  arm 
were  atrophied.  The  left  humerus  was  shortened  by  42  cm.,  and 
could  not  be  raised  quite  to  a  level  with  the  shoulder,  since  the  bone 
came  in  contact  with  the  acromion  before  it  reached  that  height. 
^\^len  discharged,  in  August,  189(),  the  patient  was  able  to  raise  his 
arm  to  an  angle  of  135  degrees.  He  Avas  allowed  33J  %  insurance, 
reduced  October  17th  to  20%,  since  at  that  date  he  could  raise  the  arm 
to  an  angle  of  about  150  degrees. 

Fractures  of  the  upper  third  or  upper  half  of  the 
humerus  arc  liable  to  lead  to  fiinetioiial  disability,  in 
spite  of  successful  union.  The  shorteniuii-  that  results 
when  the  fraonients  heal  at  more  or  less  of  an  angle  is  of 
inferior  functional  importance  than  the  ankylosis  of  the 
shoulder-joint,  which  may  persist  fot-  a  long-  time,  or  may 
even  become  permanent.  When  the  angle  formed  by  the 
fragments  after  healing  opens  inward  (j)osition  of  varus)^ 
the  head  of  the  humerus  is  Ibund  to  lie  lower  than  normal 
in  the  glenoid  cavity.  This  limits  the  range  of  motion 
of  the  shoulder-joint  and  interferes  with  the  fidl  degree 
of  action  of  the  deltoid.  The  dis])lacement  of  the  head 
of  the  humerus  in  the  glenoid  cavity,  which  can  be  recog- 
nized even  when  the  joint  is  at  rest,  causes  a  correspond- 
ing change  of  position  in  the  scapula,  limiting  its  rotation 
when  the  arm  is  raised  above  the  level  of  the  shoulder. 
Abduction  is  further  restricted  by  the  humerus  neces- 
sarily coming  in  contact  with  the  acromion  earlier  than 
normal. 

The  effect  of  an  angular  union  must,  of  course,  be 
manifested  in  the  lower  fragment  also,  and  secondarily  in 
the  elbow-joint,  contractures  of  which  are  frequently 
observed  in  these  cases.  Angular  uuion  is  most  likely 
to  take  place  when  the  line  of  fracture  lies  below  the 
insertion  of  tlie  deltoi<l,  in  which  case  the  latter  takes 
considerable  part  in  the  displacement. 


FRACTURES  OF  THE  HUMERUS.  275 

Fractures  in  the  middle  and  in  the  lower  half  of  the 
humerus  are  likely  to  involve  the  musculospiral  nerve, 
which  may  be  torn  at  the  time  of  injury  or  may  be  caught  in 
the  callus  later  on.  Unless  the  nerve  is  sutured  or  freed 
from  the  callus,  the  paralysis  becomes  permanent,  and  the 
usefulness  of  the  arm,  and  more  especially  of  the  hand,  is 
seriously  in)j)aired.  (}f  the  fractures  of  the  humerus 
in  its  lower  third,  those  due  to  overflexion  and  overex- 
tension of  the  elbow-joint  call  for  special  mention.  In 
case  of  the  former  variety  we  must  bear  in  mind  that  the 
brachialis  anticus  and  the  triceps  are  both  likely  to  be 
pierced  by  the  fragments,  while  in  case  of  the  latter 
variety  it  is  usually  the  brachialis  anticus  alone  that  is 
directly  injured.  Even  when  successfully  reduced  and 
treated  by  extension,  the  fracture  is,  in  both  instances, 
regularly  followed  by  more  or  less  ankylosis  of  the  elbow- 
joint,  requiring  a  course  of  mechanical  treatment.  If  the 
fracture  is  especially  severe  or  is  imperfectly  reduced,  it 
is  likely  to  lead  to  complete  ankylosis  of  the  elbow-joint, 
or  at  least  to  contractures  of  the  same  by  which  it  is  held 
in  an  abnormal  position. 

Weeks  or  months  may  pass  before  the  functional  dis- 
orders are  overcome  and  the  arm  regains  sufficient  strength 
to  permit  the  patient  to  resume  work.  It  may  be  consid- 
ered as  an  axiom  that  the  nearer  the  fracture  lies  to  the 
elbow-joint,  the  greater  is  the  danger  of  ankylosis  and  of 
loss  of  the  functional  power  of  the  arm. 

Fractures  of  the  lower  end  of  the  humerus  are  also 
fraught  with  danger  to  the  nerves  at  that  point,  the  muscu- 
lospiral and  median  nerves  being  more  frequently  involved 
than  the  ulnar  nerve.  They  may  be  partly  or  com])letely 
torn  across,  with  corresponding  degrees  of  paralysis  of  the 
parts  supplied.  Comj)lete  rupture  of  one  of  these  impor- 
tant nerves  permanently  and  very  greatly  inqiairs  the  func- 
tional power  and  usefulness  of  the  arm.  The  same  grave 
consequences  follow  when  the  nerve  is  caught  in  and  com- 
pressed by  the  callus. 


276  I)  ISEA  SES   CA  USED  BY  A  CC I  DENTS. 

The  following  symptoms  are  eharaeteristic  of  fractures 
of  the  lower  end  of  the  shaft  of  the  humerus  after  union 
has  taken  place  :  the  humerus  is  shortened  ;  the  arm  is  at 
first  swollen  at  the  ])oint  of  fracture  ;  later,  there  is  a 
callous  thickening  of  the  same  ;  the  fragments  may  be  dis- 
placed forward  or  backward  or  to  the  side,  resulting  in  a 
cubitus  valgus  (X-position)  or  a  cubitus  varus  (O-position) ; 
or  they  may  be  rotated  in  opposite  directions.  The  fore- 
arm is  fixed  at  an  angle  with  the  humerus  (ankylosis  or 
contractures),  causing  loss  or  impairment  of  the  functional 
power  of  the  elbow-joint,  and  to  a  certain  extent  of  the 
shoulder-joint ;  the  wrist  is  secondarily  displaced  ;  the 
muscles  of  the  arm  and  forearm,  and,  in  cases  of  paraly- 
sis, those  of  the  hand  also,  are  atrophied  and  weakened. 

The  chief  aim  of  treatment  is  to  overcome  the  anky- 
losis of  the  joints,  and  to  this  end  the  nuiscular  atrophy 
should  be  treated  by  massage  and  electricity. 

Case  of  fracture  of  the  upper  half  of  the  left  humerus,  inrolring  a 
direct  lesion  of  the  musculospiral  nerve,  followed  bij  severe  jmralysis  of  the 
latter. 

A  hod-carrier,  thirty-four  years  of  age,  ^vas  injured  on  October  23, 
188H,  by  some  Ixiards  falling  on  his  outstretchetl  ami.  The  boards  fell 
from  a  height  of  four  stories.  He  was  treated  in  tlie  hospital  until 
February  '22,  1889,  when  he  was  discharged  unimproved.  I  examined 
him  on  March  13,  1889,  and  began  treatment  by  massage  and  various 
exercises  of  the  arm.  In  Axigust  I  began  to  emi)k)y  electricity  ;  the 
reaction  of  degeneration  was  present.  In  the  beginning  of  December, 
1889,  extension  of  the  arm  was  induced  by  means  of  the  faradic  cur- 
rent ;  otherwise  the  left  arm  was  entirely  useless,  being  ankylosed  at 
))otii  the  shoulder-joint  and  ell)ow-joini3.  It  was,  in  addition,  some- 
whiit  shortened,  and  showed  a  marked  growth  of  callus  along  the  line 
of  fracture  in  the  upper  third  of  the  bone  ;  the  whole  arm  was  ex- 
tremely atrophied.  Improvement  took  place  gradually,  I)ut  only  to  a 
limited  degree.  The  wrist  and  the  fingers  could  l)e  extended  only 
with  difficulty,  and  the  arm  was  weak.  In  I)ecem))er,  1892,  the 
patient  was  allowed  50%  insurance,  reduced  in  December,  1897,  to 
40%,  at  which  rate  it  has  continued. 

C((8e  of  compound  fracture  of  the  left  humerus,  complicated  by  fracture 
of  the  coraeoid  process  and  severed  ribs.  (The  lesion  hi  the  latter  case 
was  o\ crlooked. )  The  head  of  the  radius  subsequently  became  slightly 
dis])laced.     (Fig.  31.) 

A  polisher,  sixty  years  of  age,  was  knocked  down  by  a  wooden  beam, 
which  struck  him  on  the  left  humerus  ;  in  falling  he  struck  on  the  left 


Fig.  31. 


278  DISEASES   CAUSED  BY  ACCIDENTS. 

shoulder.  He  was  treated  in  the  hospital  from  December  10,  1896, 
until  March  11,  1897.  The  injured  part  was  twice  placed  in  a  plaster 
cast,  each  cast  reniainin<;-  in  jxjsition  for  two  weeks  ;  massafi,e  was  then 
begun.     I  examined  him  on  June  2,  1897. 

The  skiagraph  shows  the  lateral  displacemeut  of  ])oth  fragments  and 
the  depression  in  the  muscles  at  this  point.  In  addition,  there  is  a 
slight  rotation  of  the  entire  lower  fragment,  including  the  trochlear 
surface  ;  also  a  consecpient  slight  i)artial  dish)cation  of  the  head  of  the 
radius  and  an  angular  position  of  the  elbow-joint.  The  forearm  could 
be  extended  only  to  an  angle  of  100  degrees  ;  on  active  motion  the  arm 
could  be  raised  to  45  degrees,  and  on  passi\"e  motion  to  70  degrees. 
The  right  coracoid  process  was  thickened.  The  patient  comi)lained  of 
some  pain  in  the  right  side  of  the  chest. 

Case  of  fracture  of  the  lower  third  of  the  right  humerus,  followed  by 
anki/losis  of  the  right  ellxtir-jnint  with  sutiset/ueut  partial  reeorery. 

A  workman,  thirty-eight  years  of  age,  on  Feln'uary  25,  1899,  fell  from 
a  scaffolding  six  feet  liigh,  sustaining  the  lesion  just  mentioned.  A  tem- 
porary bandage  was  applied,  for  which  a  plaster  cast  was  soon  substi- 
tuted. The  latter  was  renewed  two  days  later,  and  was  again  renewed 
after  an  interval  of  two  weeks,  when  it  was  allowed  to  remain  in  posi- 
tion for  another  two  weeks. 

I  first  examined  the  patient  on  March  30,  1899,  and  he  Ijegan  a 
course  of  treatment  at  my  hospital  on  April  7,  1899.  At  that  time  the 
right  arm  appeared  distinctly  shortened  ;  the  ell)ow  was  completely 
ankylosed  at  an  angle  of  120  degrees,  and  there  was  marked  callous 
thickening  of  the  humerus  aljout  a  hand's-breadtii  above  the  elbow. 
The  whole  arm  was  s\vollen  and  the  muscles  were  atrophied.  On  active 
motion  the  arm  could  l)e  raised  to  an  angle  of  45  degrees  ;  on  passive 
motion,  to  an  angle  of  110  degrees.  The  wrist  was  freely  movable. 
Treatment  consisted  in  massage,  gymnastic  exercises,  and  the  ajjplica- 
tion  of  electricity.  Tlie  patient  was  discharged  on  May  27,  1899,  wlien 
he  resumed  work.  At  that  time  his  right  ell)ow-joint  was  held  at  an 
angle  of  140  degrees  and  could  l)e  flexed  \\  itli  ease  to  an  angle  of  75 
degrees,  while  the  arm  could  l)e  alxlucted  to  170  degrees.  The  swell- 
ing and  atrophy  were  decidedly  less  marked  and  tlie  arm  had  gained 
consideral)ly  in  strength.     Insurance  allowance,  25'^  . 

Case  of  fracture  of  the  lower  third  of  the  right  humerus,  with  subsequent 
anki/losis  of  the  elbow-Joint. 

A  mason,  thirty-three  years  of  age,  fell  from  a  wall  twenty-five  feet 
high  on  April  22,  1887,  sustaining  the  injury  just  nu'ntioned.  He  was 
treated  for  one  week  in  the  hospital  and  then  at  liis  house.  He  came 
under  my  care  on  July  15,  1HS7,  at  which  time  his  elbow-joint  was 
completely  ankylosed  at  an  angle  of  135  degrees.  Wlien  discharged, 
on  May  13,  1888,  the  elbow-joint  could  )»e  flexed  to  an  angle  of  00 
degrees,  and  could  l)e  extended  to  an  angle  of  175  (U'gi'ees.  Insurance 
allowance,  33j%.  On  October  17,  1888,  examination  showed  further 
improvement,  the  elbow  being  held  at  an  angle  of  105  degrees.  The 
allowance  was,  therefore,  reduced  to  15%.  On  July  27,  1894,  he  was 
declared  to  be  completely  cured,  and  could  perform  the  work  of  a  mason 
as  well  as  ever. 


FRACTURES  OF  THE  IirMERUS.  279 

Fractures  of  the  lower  articular  extremity  of  the 
humerus  belong  to  fracture.s  of  the  elbow-joint.  They 
occur  in  many  cliti'erent  forms.  They  are  observed  with 
great  freciuency  in  combination-forms.  In  case  of  frac- 
tures of  the  internal  condyle  (inner  ol)lique  fracture), 
which  is  seldom  seen,  tiie  broken  fragment  is  likely  to 
be  displaced  outward  and  do\vnward  by  the  action 
of  the  pronator  radii  teres,  while  it  is  at  the  same 
time  drawn  downward  l>y  the  flexor  carjn  radialis 
and  the  flexor  snl)limis  digitorum.  Displacement  is  espe- 
cially likely  to  occur  after  rupture  of  the  internal  lateral 
ligament.  After  union  takes  place  there  may  be  a  more 
or  less  well-marked  0-position  (cubitus  varus),  the  elbow- 
joint  being  at  tiie  same  time  flexed.  All  the  muscles 
arising  from  the  internal  condyle  undergo  atrophy.  The 
ulnar  nerve  is  exposed  to  direct  injury  in  fractures  at  this 
point. 

Fractures  of  the  internal  condyle  frequently  occur  in 
connection  with  dislocation  of  the  forearm. 

The  external  condyle  is  more  frequently  fractured 
than  the  internal ;  union  usually  takes  place  in  an  X- 
position  (cubitus  valgus)  of  the  elbow-joint. 

Fractures  of  either  condyle  usually  leave  the  joint 
flexed  and  at  the  same  time  ankylosed.  In  case  of  frac- 
ture of  tiie  internal  condyle  the  flexors  are  primarily 
affected  by  atrophy,  while  in  case  of  fracture  of  the  external 
condyle  it  is  the  extensors  that  are  primarily  aflt'cted,  the 
antagonists  in  both  cases  becoming  atrophied  secondarily. 
Paralysis  and  trophoneurotic  disorders  may  appear  in 
consequence  of  injury  to  the  nerves, 

Sej)aration  of  the  internal  epicondyle  may  be  caused 
by  direct  violence,  but  is  more  fre((uently  tiie  result  of 
indirect  violence  in  the  form  of  sudden  and  very  forcible 
abduction  of  the  arm,  the  epicondyle  being  torn  off'  by 
tlie  internal  lateral  ligament.  It  is  not  definitely  de- 
cided whether  or  not  tlie  lesion  can  be  produced  by  con- 
traction of  the  pronator  radii  teres. 


280  DISK  A  SES   CA  USED  BY  A  CCI DENTS. 

Separation  of  the  external  ejiicondyle  is  a  rare  lesion. 
I^nless  decidedly  displaced,  no  permanent  functional  dis- 
orders are  to  be  expected  in  case  of  separation  of  either 
epicondyle ;  the  muscular  atrophy  is  soon  overcome. 

After-treatment  of  fracture  of  the  humerus  is  chiefly 
directed  tc)ward  the  mobilization  of  the  ankylosed  joints. 
Gradual  loosening  of  the  adhesions  is  to  be  preferred  to 
forcible  rupture,  for  the  reason  that  the  latter  is  apt  to 
lead  to  the  formation  of  new  adhesions,  if  to  nothing;  nrore 
serious.  Forcible  rupture  is  to  be  recommended  only  for 
the  purpose  of  obtaining  a  more  favorable  tixed  position 
of  the  joint.  Recovery  is  best  furthered  by  passive  move- 
ments and  medicomechanical  exercises,  in  connection  Avith 
massage,  local  baths,  and  electricity.  If  paralysis  is 
caused  by  pressure  on  a  nerve,  in  eonseciuence  of  the 
growth  of  callus,  the  nerve  should  be  freed  from  the  latter 
by- operation. 

The  degree  to  which  the  patient  is  incapacitated  for 
self-support  depends  on  his  functional  disal)ility.  If  he 
can  raise  his  arm  to  an  angle  of  about  110  degrees,  30^; 
insurance  allowance  is  usually  sufficient  when  the  right 
arm  is  involved,  25  ^  when  the  left  arm  is  involved.  If 
he  can  raise  it  only  to  a  level  with  his  shoulder,  40  ^,  for 
the  right  arm  and  30^;  for  the  left  is  an  a})propriate 
allowance,  the  allowance  being  estimated  at  a  higher  rate 
for  more  serious  degrees  of  ankylosis.  For  recurrent  dis- 
location :  if  occurring  on  active  motion,  60^  for  the  right 
ajnn  and  50^  for  the  left ;  if  occurring  on  passive  motion, 
75^,  for  the  right  arm  and  GO^  for  the  left.  Compen- 
sation for  lesions  of  the  elbow-joint  will  be  discussed  in 
the  following  chapter. 

3.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
ELBOW=JOINT. 

Considerations  «s  to  Anatotny  and  Function. — Movement  of  tlie  elbow- 
joint  is  limited  to  flexion,  extension,  and  rotation,  the  last  beinj^  dis- 
tinjrnished,  according  to  its  direction,  as  jironation  (inward  rotation) 
and  supination  (outward  rotation). 


INJURIES  TO  THE  ELBOW.  281 

Flexion  is  prodiifod  both  at  the  joint  between  the  humerus  and  the 
nhia,  and  at  that  l)et\veeu  the  humerus  and  tlie  radius.  It  is  cliiefly 
executed  on  the  iinier  grooved  portion  of  the  troeldear  surface,  which 
in  the  right  arm  is  directed  to  the  left,  and  in  the  left  arm  is  directed 
to  the  riglit.  As  a  result  of  the  inclination  of  this  surface,  the  forearm 
does  not  form  a  straight  line  with  the  arm,  either  when  completely 
flexed  or  when  completely  extended.  On  flexion  it  approaches  the 
chest ;  on  extension  it  moves  in  the  oi)posite  direction,  forming,  when 
fully  extended,  an  angle  w  ith  tlie  arm  the  base  of  which  is  directed 
outward. 

Extension  can  he  carried  to  an  angle  of  about  180  degrees,  some- 
times more  ;  it  is  limited  by  the  contact  of  the  apex  of  the  olecranon 
with  the  olecranon  fossa. 

Flexion  is  limited  by  contact  between  the  coronoid  process  of  the 
ulna  and  the  coronoiil  fossa,  and  can  he  carried  to  an  angle  of  aV>out  30 
degrees.  The  ft)rearm,  therefore,  has  a  total  range  of  motion  in  flexion 
and  extension  of  150  degrees.  The  olecranon  and  coronoid  fossse  are 
separated  by  a  very  thin  lamina  of  bone.  Overflexion  and  overexten- 
sion are  prevented  by  the  tension  of  the  lateral  ligaments  of  the  elbow-' 
joint. 

The  movements  of  pronation  and  supination  are  executed  chiefly  in 
the  upper  radio-ulnar  joint,  assisted,  when  the  forearm  is  flexed,  by 
the  joint  between  the  humerus  and  head  of  the  radius,  and,  lastly,  by 
the  lower  radio-idnar  joint.  The  range  of  motion  in  pronation  and 
supination  etjuals  an  arc  of  180  degrees.  During  rotation  the  orbicular 
ligament,  which  encircles  the  head  of  the  radius  and  is  inserted  into 
the  margins  of  the  lesser  sigmoid  cavity  of  the  ulna,  plays  the  part  of 
a  sliding  plane. 

The  capsule  of  the  elbow-joint  is  thin  anteriorly,  and  still  thimier 
posteriorly  ;  ))ut  in  the  latter  situation  it  is  reinforced  by  the  trice])s 
and  its  tendon.  Laterally,  it  is  strengthened  ])y  the  internal  and  ex- 
ternal lateral  ligaments.  Flexion  of  the  elbow-joint  is  produced  by 
the  brachialis  anticus  (supplied  by  the  musculocutaneous  nerve), 
assisted  by  the  l)iceps,  which  also  acts  as  a  supinator  of  the  forearm. 
The  brachialis  anticus  arises  from  the  internal  and  external  surfaces  of 
the  humerus  and  is  inserted  into  the  coronoid  process  of  the  ulna  ; 
although  it  must  l)e  regarded  as  the  chief  agent  of  flexion,  its  short 
leverage  disqualifies  it  for  acting  jwwerfully  A\ithout  assistance.  The 
biceps  (sup]ilied  by  the  nmsciilocutaneous  nerve)  must,  therefore,  not 
be  underrated  in  its  capacity  of  flexor.  The  fact  that  at  the  same  time 
it  acts  as  a  su])inator  is  sufficiently  explained  by  its  insertion  into  the 
tuberosity  of  the  radius  and  the  fascia  of  the  anterior  surface  of  the 
forearm. 

The  elboM' -joint  is  extended  by  the  triceps,  a.ssisted  by  the  anconeus. 

Pronation  is  effected  liy  the  following  muscles  :  the  pronator  radii 
teres,  flexor  car\n  radialis,  pronator  quadratus,  and  supinator  longus. 

Supination  is  effected  by  the  biceps,  by  the  supinator  bre^•is,  and, 
to  a  certain  extent,  ])y  the  supinator  longus. 

Injuries  and  diseases  of  the  ell)ow-joint  or  of  adjacent  structures 
have  the  effect  of  limiting  or  suspending  the  functional  action  of  the 


282  DISEASES  CAUSED  BY  ACCIDENTS. 

joint.  Functional  power  is  also  restricted  by  patliologie  changes  in 
the  shoulder  or  wrist. 

In  examining  the  elljow-joint  the  affected  joint  should  first  be  com- 
pared with  that  of  the  opposite  side;  its  functional  action  should  then 
be  tested,  noting  the  range  of  the  different  movements  with  the  aid  of 
the  goniometer.  Palpation  should  next  be  practised,  and,  finally,  the 
musc^les  of  the  arm,  forearm,  shoulder,  and  wrist  should  be  carefully 
examined. 

SUdifiiics. — The  103  cases  of  injury  of  the  elbow-joint  upon  which 
the  following  sections  are  based  were  divided  as  follows  :  29  cases  of 
contusions,  sprains,  and  wounds:  7  cases  of  sim])le  s])i-ain;  24  disloca- 
tion-fractures; 12  simple  dislocations;  'M  fractures.  The  right  arm 
Avas  involved  in  54  cases,  the  left  in  45  cases;  both  arms  were  involved 
in  4  cases. 

Contusions  of  the  EIbow=joint. 

Contusions  clue  to  falls  g-ive  rise  to  extravasation  of 
blood  and  to  8\v(>lling',  which  very  soon  disapi)ear  unless 
the  contusion  is  complicated  by  some  more  serious  injury. 
Com])licatious  are,  however,  not  infrequently  met  with  in 
the  shape  of  a  fracture  of  the  humerus  (supracondyloid 
fracture),  the  olecranon,  or  some  other  part  of  the  elbow- 
joint.  The  ulnar  nerve  is  sometimes  directly  affected  by 
the  contusion.  The  olecranon  bursa  beneath  the  tendon 
of  the  triceps  frecpiently  becomes  the  seat  of  an  acute  in- 
flammation, which,  unless  carefully  treated,  may  lead  to 
suppuration.  These  various  complications  serve  to  delay 
to  a  considerable  extent  the  progress  of  recovery. 

Sprains  of  the  EIbow=joint. 

This  lesion  is  produced  by  a  fall  on  the  hand  or  elbow 
or  by  violent  traction.  It  may  be  simple  or  may  be  com- 
plicated by  fracture  ;  in  any  case,  it  is  accompanied  by 
partial  laceration  of  the  ligaments  and  capsule  of  the  joint, 
the  consequences  of  which  are  seen,  after  the  swelling  and 
inflammation  have  subsided,  in  a  certain  degree  of  loose- 
ness and  insecurity  of  the  joint,  together  with  atrophy  and 
weakness  of  the  muscles.  These  symptoms  persist  for  a 
considerable  length  of  time. 

The  symptoms  of  contusions  and  sprains  of  the  elbow- 
joint  to  be  seen  when  the  acute  appearances  have  subsided 


DISLOCATION  OF  THE  ELBOW.  283 

are  :  Contractures  of  the  joint  by  whieli  the  hitter  is  fixed 
at  an  angle  ;  musenhir  atrophy  ;  limitation  of  motion 
(flexion,  extension,  rotation)  ;  weakness  of  the  muscles. 

The  treatment  consists  of  systematic  exercises  and  mas- 
sage. The  average  insurance  allowance  varies  from 
0  to  20  '/r  . 

External  lesions  of  the  elbow-joint,  wounds  of  various 
kinds,  and  burns,  result  in  the  formation  of  cicatrices, 
which  sometimes  become  attached  to  the  bone  or  to  the 
tendon  of  the  triceps.  The  contractures  of  the  joint  that 
follow  can  be  relieved,  if  not  entirely  overcome,  by  me- 
chanical treatment.  In  severe  cases  skin-grafting  is  in- 
dicated. The  cicatrix,  if  attached  to  the  bone,  should  be 
freed  by  operation.      Insurance  allowance,  up  to  20^. 

Dislocation  of  the  EIbow=joint. 

Although  statistics  in  general  show  the  elbow-joint  to 
be  involved  in  about  18^  of  all  cases  of  dislocation,  the 
lesion  is  not  often  seen  in  workmen  who  have  reached 
middle  age  or  over.  Dislocation  of  the  elbow-joint  is 
usually  caused  by  a  fall  on  the  hand.  In  young  persons  a 
dislocation,  if  reduced  in  time,  is  soon  followed  by  complete 
recovery.  The  lesion  as  it  occurs  in  adults  is  apt  to  be 
accompanied  by  fracture,  usually  resulting  in  ankylosis, 
and  invariably  so  if  the  dislocation  remains  unreduced. 
After  firm  adhesions  have  formed  reduction  can  be  ac- 
complished only  with  great  difficulty,  and  if  bony  union  has 
taken  place,  it  may  be  quite  impossil)le.  In  cases  in  which 
the  joint  is  fixed  at  an  obtuse  angle  the  condition  of  the 
patient  is  greatly  improved  by  changing  the  position  to  one 
of  flexion  at  a  right  angle,  combined  with  supination. 

Even  when  uncomplicated  by  fracture  and  successfully 
reduced,  a  dislocation  of  the  elbow-joint  can  be  recognized 
for  some  time  by  certain  characteristic  symptoms.  The 
joint  is  more  or  less  fixed  in  a  position  of  flexion  (cubitus 
valgus  or  occasionally  cid)itus  varus),  depending  on  the 
seat  and  extent  of  the  tear  in  the  joint-capsule  and  the 


284  DISEASES  CAUSED  BY  ACCIDENTS. 

consequent  amount  of  cicatricial  tissue.  The  condition 
frequently  calls  for  systematic  treatment  by.  massage  and 
passive  movement.  At  the  time  of  dislocation  the  bra- 
chialis  anticus  is  usually  more  or  less  torn  at  its  point  of 
insertion,  while  the  tendon  of  the  biceps  and  the  bicip- 
ital fascia  are  subjected  to  strain.  The  tendon  of  the  tri- 
ceps is  also  likely  to  be  somewhat  injured.  Atrophy  of 
these  muscles  frequently  occurs,  therefore,  resulting  in 
diminished  power  of  flexion  and  extension  and  in  weak- 
ness of  the  arm.  If,  as  occasionally  happens,  the  coronoid 
process  is  torn  off,  the  atrophy  of  the  brachialis  anticus  is 
correspondingly  marked  and  persistent.  This  lesion  is 
most  likely  to  be  found  in  cases  of  backward  dislocation. 
Lateral  dislocation  may  be  complicated  by  fracture  of 
one  of  the  condyles,  leading  to  functional  disorders  which 
have  already  been  discussed  under  fractures  of  the 
humerus.  Backward  dislocation  is  frequently  compli- 
cated by  fracture  of  the  olecranon,  leading  to  rapid  atro- 
phy of  the  triceps,  and,  secondarily,  of  its  antagonists. 
Recovery  may  furthermore  be  delayed  by  injury  to  the 
blood-vessels.  The  ulnar  nerve  has  occasionally  been 
found  displaced  ;  functional  ])()\ver  was,  however,  restored 
in  the  course  of  a  few  months. 

The  fractures  of  the  elbow-joint  that  have  not  already 
received  mention  will  be  discussed  under  fractures  of  the 
forearm. 

As  already  stated,  unreduced  dislocations  of  the  elbow- 
joint  invariably  lead  to  permanent  ankylosis  of  the  latter. 

The  position  most  favorable  to  the  usefulness  of  the  arm 
in  cases  of  complete  ankylosis  is  that  of  flexion  at  a  right 
angle,  combined  with  a  moderate  degree  of  supination. 
With  the  arm  in  this  ])osition,  although,  as  a  rule,  ham- 
pered by  a  slight  stiftnessof  the  shoulder-joint,  the  ])atient 
is  able  to  perform  numerons  movements,  such  as  carrying 
the  hand  to  the  mouth,  ])uttiiig  the  hand  in  the  pocket, 
etc.,  whereas,  if  the  forearm  is  fixed  in  pronation,  the  arm 
is  practically  useless. 


Fig.  32. 


286  DISEASES  CA  USED  BY  A  CC I  DENTS. 

Partial  resection  may  yield  a  relatively  useful  nieniber, 
but  it  is  sometimes  followed  by  shortening  and  ankylosis. 
The  statements  just  made  concerning  primary  ankylosis  are 
equally  applicable  to  postoperative  ankylosis.  The  opera- 
tion occasionally  results  in  loose-jointedness.  which  is, 
as  regards  function,  a  most  unfavorable  outcome  in  the 
majoritv  of  cases.  The  patient  should  be  provided  with 
a  jointed  support  for  the  elbow. 

The  insurance  allowance  is  60^.  for  the  right  arm, 
bO%  for  the  left,  when  completely  ankylosed  at  an  obtuse 
angle;  40^  for  the  right,  :5()^  for  the  left,  if  at  a  right 
angle.  The  allowance  for  inflanmiation  and  tuberculosis 
of  the  elbow-joint  is  estimated  as  in  cases  of  similar  lesions 
in  the  shoulder-joint. 

Caw  of  (lis.]nr(ttion  of  the  had  of  ilw  radium  and  rcuniti d  fradure  of 
the  coroHoid  process:.  ( Fig.  32,  p.  285. )  Secjucls,  ankylosis  of  tlie  elbow- 
joint  and  disorders  of  mobility  of  the  slioulder-joint  and  wrist. 

A  mason,  thirty-eight  years  of  age,  fell  from  a  scaffolding  on 
September  18,  1890,  sustaining  tlu'  foregoing  injuries. 

When  I  examined  him  on  January  10,  1H91,  I  found  the  left  elbow- 
joint  held  at  an  angle  of  I'iO  degrees  ;  llexion  was  limited  to  an  angle 
of  75  degrees.  Active  abiluction  carried  the  arm  to  80  degrees  ;  pas- 
sive abduction,  to  95  degrees.  The  nuiscles  were  greatly  atrophied. 
The  ^vrist  was  somewhat  stiff  at  first,  but  subsequently  regained  its 
mol)ility  completely.     The  left  arm  was  the  seat  of  paresthesia. 

In  the  accompanying  .skiagraph  the  condition  of  the  elbow-joint  is 
clearly  shown  ;  the  notch  on  the  coronoid  process  is  distinctly  visible, 
and  tiie  head  of  the  radius  can  be  recf)gnized  l)e_\ond  the  ulna. 

Case  of  poorly  united  coiiimiiiitied  fraeture  of  the  left  eUxnr-Joint,  lend- 
ing to  ankylosis  and  looxe-Jointcdnrss,  irith  seeondary  ankijloxis  of  the 
shoulder  and  wrist.     (Fig.  33,  p.  287.) 

A  carpenter,  thirty-eight  years  of  age,  fell  from  a  roof  nine  feet  high 
on  July  1,  1893.  After  being  under  treatnumt  for  fifteen  nuHiths  for 
a  sprain  of  the  elbow-joint,  he  fell  down-stiiirs,  again  injuring  the 
elbow.  He  was  sent  to  me  for  a  c(mrse  of  after-treatment  on  Sei)tember 
9,  1898,  after  having  been  treated  by  several  other  ])liysicians.  I 
found  the  left  elbow-joint  flexed  at  an  angle  of  135  degrees,  the  fore- 
arm being  at  the  same  time  very  strongly  supinated.  The  whole  left 
arm  was  greatly  atrophied.  The  <']bow-joint  was  in  a  condition  of 
loose-jointedness  and  was  incapable  of  active  movement,  either  of 
flexion  or  extension.  The  .shoulder-joint  Avas  completely,  and  the 
wrist-joint  partly,  ankylosed.  No  improvement  has  taken  place  up  to 
date.     Insurance  allowance,  fiO^. 


Fig.  33. 


288  DISEASES   CAUSED  BV  ACCIDENTS. 

Case  of  comminuted  fracture  of  the  right  elbow-joiut,  accompanied  by 
backward  dislocatioii  of  the  forearm.     (Fig.  34,  p.  289. ) 

A  carpenter,  twenty-two  years  of  age,  fell  from  a  roof  two  stories 
high,  on  March  7,  1H98,  sustaining  the  foregoing  injury.  He  was 
treated  first  in  the  hospifcil,  subsequently  at  home,  coming  under  my 
care  on  April  25,  1898.  At  that  time  the  elbow-joint  was  completely 
ankylosed  at  an  angle  of  125  degrees,  and  was  at  the  siune  time  so 
strongly  supinated  that  the  patient  could  use  it  neither  in  dressing  nor 
in  feeding  himself.  Abduction  at  the  shoulder-joint  was  limited  to 
75  degrees  ;  mobility  at  the  wrist-joint  was  practically  normal. 

The  skiagraph  shows  the  back\\ard  dislocation  of  the  forearm,  the 
lines  of  fracture  on  the  olecranon  process  and  trochlear  surface,  and 
the  displacement  of  the  fragments  in  the  latter  case  ;  also  the  bony 
union  with  the  coronoid  process. 

An  attempt  to  reduce  the  dislocation  was  unsuccessful  on  account 
of  the  bony  union  which  had  already  taken  place.  The  position  of  the 
elbow-joint,  however,  was  changed  to  nearly  that  of  a  right  angle,  and 
the  degree  of  supination  Avas  reduced.  Suljsequent  treatment  com- 
pletely restored  the  functional  power  of  the  right  shoulder-joint. 

AMien  discharged,  the  patient  could  use  his  arm  for  dressing  himself 
for  eating  and  for  various  other  ]mrposes.  Insurance  allowance,  50%. 
At  the  present  time  he  is  employed  at  easy  work  for  eleven  hours  a 
day. 

The  accompanying  skiagraph  shows  the  condition  subse(iuent  to  the 
attempted  reduction. 

Case  of  loose-jointedness  of  the  elbow  following  resection  of  the  lower 
end  of  the  hnmertis. 

A  workman,  forty  years  of  age,  sustained  a  comminuted  fracture  of 
his  right  luuuerus  on  May  10,  1889,  caused  by  the  fall  of  a  cog-wheel 
on  his  outstretched  arm.  ^  He  was  treated  in  the  hospital,  where  a  re- 
section was  made  of  the  lower  end  of  the  humerus,  including  the  artic- 
ular surface. 

I  examined  him  on  August  9,  1889.  His  arm  below  the  line  of 
resection  hung  limply  at  his  side  ;  he  could  move  neither  foreainn  nor 
fingers.  He  was  supplied  with  a  jointed  support,  which  held  the  arm 
at  a  convenient  right  angle  and  enabled  him  to  lift  light  articles.  In- 
surance allowance,  80  % . 


4.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
FOREARM. 

Slatisties. — The  cases  of  injury  of  the  forearm  serving  as  a  basis  for 
the  following  sections  numl)er,  in  all,  2(n,  l)eing  classified  as  follows  : 
205  cases  of  fracture;  .'U  of  contusions  and  contusion-wounds;  14  of 
incised  and  punctured  wounds;  11  of  burns.  The  right  forearm  was 
involved  in  121  cases,  the  left  in  127  cases;  both  were  injured  in  13 
cases. 


Fig.  34. 


290  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  20. 

Case  of  Rupture  of  Muscles  and  Tendons  of  the  Forearm 
in  a  Case  of  Injury  Due  to  the  Caving=in  of  a  Wall. 

A  hod<"ai-rier,  tliirty-four  years  of  age,  while  employed  in  tearing 
down  a  building  Avas  caught  under  a  falling  A\all,  on  INIay  7,  18H9. 
He  sustained  a  severe  compound  fracture  of  the  skull,  and,  in  addi- 
tion, his  right  forearm  was  badly  crushed.  He  Avas  treated  in  the 
hospital,  Avhere  the  ruptured  tendons  were  sutured. 

The  accompanying  illusti'ation  s1k)ws  the  scar  on  the  anterior  sur- 
face of  the  forearm  and  a  nuiscle-hernia  at  the  middle  of  the  latter. 
The  effort  of  the  patient  to  close  the  hand  is  also  dejjicted ;  he  w'as 
unable  to  Hex  the  fingers  further.  The  nmscle-hernia  was  most  promi- 
nent with  the  hand  in  this  position.  The  strength  of  the  right  arm 
was  not  more  than  half  that  of  the  left.  The  patient  was  an  unusu- 
ally' strong  and  vigorous  man.    The  insurance  allowance  was  only  10% . 


Contusion  and  Crushing  of  the  Forearm. 

Unless  complicated  by  serious  avouikIs  of  the  skin,  by 
lacerations  of  muscles,  tendons,  and  nerves,  or  l)y  fracture, 
contusions  of  the  forearm  usually  heal  without  unfavorable 
consequences. 

The  forearm  is,  however,  exposed  io  very  grave  acci- 
dents, especially  among  workmen  in  the  trades  and  manu- 
factures, as  a  result  of  which  it  may  be  severely  crushed 
and  permanently  disabled.  Accidents  of  this  nature  fre- 
quently occur  during  the  loadiug  and  unk)ading  of  heav^y 
beams,  in  overturning  heavy  blocks  of  granite,  or  when,  in 
tearing  down  a  buikliug,  a  worlvman  is  caught  under  fall- 
ing walls  and  debris.  In  tlie  latter  instauce  the  injury  is 
likely  to  be  especially  serious,  since  skin,  muscles,  and 
tendons  may  easily  be  torn  by  sharp  edges  or  pointed 
masses. 

Cases  of  crushing  and  mangling  of  an  extremely  severe 
type,  involving  muscles  and  tendons  and  accomj)anied  by 
extensive  burns,  occur  occasionally,  although  with  relative 
infrequency,  in  steam  laundries  when  hand  and  forearm 
are  drawn  in  between  hot  rollers. 


Lao,   L'U. 


..^ 


J*' 


\       \ 


WOUNDS  OF  THE  FOREARM.  291 

Severe  case  of  mnngling  of  the  left  hand  and  forearm  accompanied  by 
burns. 

A  working-girl,  eighteen  years  of  age,  employed  in  a  steam  laundry, 
sustained  the  injuries  of  the  hand  and  forearm  just  mentioned  on  Decem- 
ber 16,  1892,  the  arm  Iteing  drawn  in  between  hot  rollers.  She  was 
treated  in  the  hospital  until  August  27,  1893,  when  a  course  of  medico- 
mechanical  treatment  A\"as  t)egun. 

I  examined  her  on  January  29,  1894.  The  left  forearm  was  pro- 
nated,  the  wrist-joint  was  swollen,  and  the  fingers,  wrist-joint,  and 
elbow-joint  were  ankylosed.  They  responded  slightly  to  pavssive 
motion.  The  extensor  surface  of  the  forearm  was  marked  by  two 
long,  wide,  and  adherent  scars,  reaching  up  to  the  elbow-joint,  and 
the  whole  arm  Avas  entirely  useless.  The  i)atient  Avas  discharged  on 
March  17,  1894,  with  an  insurance  allowance  of  60%. 

The  liand  and  forearm  are  also  sometimes  frightfully 
mangled  by  being  caught  between  eog-wheels.  No  gen- 
eral statements  can  be  made  concerning  the  consequences 
of  such  injuries ;  each  case  must  be  judged  for  itself. 
For  the  symptoms  observed  in  special  instances  the  reader 
is  referred  to  the  illustrative  cases  here  cited. 

Wounds  of  the  Forearm, 

The  greatest  possible  variety  of  wounds  of  the  forearm 
is  met  with  in  Avorkmen  employed  in  the  various  trades 
and  manufactures. 

Reference  has  already  been  made  to  the  wounds  accom- 
panying contusions. 

Incised  wounds  are  produced  by  pieces  of  glass,  the 
splinters  of  which  are  a})t  to  remain  in  the  wound ;  also 
by  sharp  pieces  of  tin,  by  knives,  saws,  pieces  of  slate, 
etc. 

Punctured  wounds  are  caused  by  penetration  of  scissor- 
points  and  similar  instruments. 

In  respect  to  sequels,  extensive  scars  of  the  forearm 
are  likely  to  limit  the  mobility  of  the  elbow-joint,  wrist, 
and  fingers. 

If  a  punctured  wound  happens  to  sever  a  large  nerve- 
branch,  the  consequences  are,  of  course,  most  serious,  as  I 
had  occasion  to  observe  in  one  case  of  paralysis  of  the 
muscles  supplied  by  the  musculospiral  nerve.     This  nerve 


292  DISEASES   CAUSED  BY  ACCIDENTS. 

liad  been  severed  by  a  punctured  wound  on  the  extensor 
surface  of  the  right  arm  in  its  upper  third. 

Incised  wounds  running  transversely  across  the  lower 
third  of  the  forearm,  especially  if  close  to  the  wrist,  are 
attended  by  the  danger  of  more  or  less  serious  injury  to 
tiie  uniscles,  tendons,  and  nerves  at  that  point.  8uch 
wounds  are  produced  by  blows  from  an  ax  or  hatchet,  by 
cuts  made  by  a  circular  saw  or  some  other  sharp  machine, 
or  by  glass,  slate,  and  thediiferent  edged  materials  of  trade. 
If  properly  reunited  by  sutures,  the  tendons  and  nerves  may 
be  restored  to  power  ;  it  happens  sometimes,  however,  that 
the  tendons  are  not  properly  united  at  operation,  or  that 
the  sutures  subsequently  give  way,  and  in  such  cases  func- 
tional power  is  greatly  impaired.  Even  when  the  nerves 
are  only  partly  severed,  as  can  l)e  determined  on  examina- 
tion, the  forearm  recovers  its  full  pcnver  very  slowly  and 
gradually,  perliaps  not  until  several  years  have  elapsed. 

The  fact  that  trivial  injuries  may  be  followed  by  cellu- 
litis, by  which  the  part  can  be  rendered  almost  useless, 
does  not  need  further  discussion  here. 

Burns  of  the  Forearm. 

These  are  of  functional  importance  if  tluy-  involve  the 
skin  over  the  wrist-joiut  or  elbow-joint.  As  the  skin  of 
cicatricial  tissue  is  frequently  in  an  atrophic  condition,  it 
is  likely  to  break  open  and  is  veiy  sensitive  to  cold  ;  areas 
of  hyperesthesia  are,  moreover,  not  infrequently  presented. 

Fractures  of  the  Forearm. 

The  following  points  may  be  stated  in  regard  to  the 
fracture  of  those  portions  of  the  bones  of  the  forearm  that 
are  contained  within  the  joint. 

The  olecranon  may  be  torn  off  by  muscular  action  or 
may  be  directly  fractured  by  a  fall.  In  either  case  it  is 
drawn  upward  by  the  triceps,  the  displacement  being 
frequently  followed  by  fibrous  rather  than  by  bony  union. 


FRACTURES  OF   THE  FOREARM.  293 

The  triceps  mideriroes  primary  atr()])liy,  Avhieli  is  followed 
by  seeoudary  involvement  of  the  bice})s,  braehialis  antieus, 
coracobrachialis,  and  the  muscles  of  the  forearm.  In 
some  cases  the  })atient  recovers  the  full  use  of  the  arm  ; 
in  others,  he  is  obliged  to  wear  a  jointed  support  for  the 
elbow  in  order  to  work  to  any  advantage.  The  fractured 
olecranon  may  become  fixed  by  bony  union  in  or  beside 
the  olecranon  fossa,  rather  than  at  the  point  of  fracture. 
After  fracture  of  the  olecranon  the  functional  power  of  the 
arm  is  always  impaired  for  the  time  being,  and  in  some 
cases  the  disability  is  permanent.  Direct  fractures  are 
likely  to  involve  the  ulnar  nerve,  in  which  case  the 
symptoms  of  functional  disorder  are,  of  course,  increased 
in  severity. 

Case  of  fracture  of  the  right  olecranon  due  to  a  fall  from  the  halconi)  of 
a  theater.  Sequel,  displacement  of  the  olecranon,  leaving  an  interval 
of  the  width  of  a  finger  Ijetween  the  fragments.  One  year  after  iiijuiy 
the  patient  was  comparatively-  well  able  to  support  himself  at  his 
trade. 

A  mason,  thirty-eight  years  of  age,  fell,  as  just  described,  on  No- 
vember 26,  1889,  sustaining  a  fracture  of  the  right  olecranon.  He 
was  first  treated  in  the  hospital,  then  in  the  dispensary.  I  examined 
him  February  21,  1890,  and  he  remained  in  my  care  until  December 
20th,  of  the  same  year.  Insurance  allowance,  33*^^.  During  that 
time  the  atrophy  of  the  arm  increased,  while  the  triceps  showed  rela- 
tive impro\"ement.  The  arm  could  be  alxluctcd  to  an  angle  of  I.jO 
degrees  ;  the  elbow-joint  was  held  flexed  at  an  angle  of  85  degrees. 
The  patient  A\as  given  a  jointed  support,  by  the  aid  of  which  he 
learned  to  perform  most  of  the  work  of  his  trade.  Insurance  allow- 
ance since  November,  1891,  25%. 

Case  of  fracture  of  the  left  olecranon  caused  hy  falling  and  striking  on 
the  elbow,  folloired  hi/  aevere  functional  disability. 

A  mason,  forty-seven  years  of  age,  slii)i)ed  and  fell  into  a  lime-pit 
on  July  18,  1891.  He  was  first  treated  in  a  disiiensary,  entering  my 
care  on  October  19,  1891.  At  that  time  the  left  elbow-joint  was 
flexed  at  an  angle  of  140  degrees  ;  the  olecranon  was  displaced  upward 
by  the  width  of  a  finger  and  was  freely  movable.  The  musc-les  were 
greatly  atrophied  ;  the  patient  complained  of  the  arm  being  cold,  and 
was  unable  to  close  the  hand  completelv.  Insurance  allowance, 
60%. 

When  the  coronoid  process  is  broken  off  at  its  base, 
union  is  always  succeeded  by  ankylosis  of  the  joint  and 
atrophy  of  the  braehialis  antieus.      If  the  ankylosis  is  com- 


294  DISEASES   CAUSED  BF  ACCIDENTS. 

plete,  the  atrophy  of  tlie  muscle  becomes,  of  course,  a 
matter  of  secondary  cunsideration. 

Fracture  of  the  Ulna  in  its  Upper  Third,  Accom- 
panied by  Upward  Dislocation  of  the  Head  of  the 
Radius. — This  may  be  looked  U[)ou  as  one  of  the  typical 
fractures  of  the  forearm.  As  I  have  repeatedly  had  oc(!a- 
sion  to  observe,  when  allowed  to  remain  unreduced,  this 
lesion  presents  the  following-  characteristic  signs  after 
union  is  established  :  the  elbow-joint  is  flexed  and  com- 
pletely or  almost  completely  ankylosed  ;  the  ulna  is  bent 
at  an  angle  the  concavity  of  which  is  directed  outward  ; 
the  head  of  the  radius  shows  distinctly  under  the  slcin  ; 
and  the  whole  forearm  appears  shortened.  As  is  to  be 
expected  in  all  cases  of  ankylosis  of  the  elbow-joint,  the 
mobilitv  of  the  sii(iuld(M-joint  is  secondarily  im[)aired. 

Fractures  of  the  Shaft  of  the  Ulna. — Fractures  of 
the  shaft  are  in  most  cases  caused  by  direct  violence, 
as  from  a  fall  on  the  inner  side  of  the  forearm.  After 
union  is  established  the  ulna  is  usually  found  shortened 
and  bent  at  an  angle  the  concavity  of  which  is  directed 
inward.  Cases  are  on  record,  however,  in  which  fracture 
occurred  during  the  process  of  lifting  heavy  weights  or  of 
setting  them  down  when  the  forearm  was  flexed.  A  frac- 
ture occurring  under  such  <nrcumstances  does  not  neces- 
sarily indicate  a  pathologic  condition  of  the  bone,  as  is 
shown  by  the  following  case  : 

CW.sc  nf  fracture  of  the  right  ulna  caused  Ijjj  lifting  a  hearij  hundle  o/  //«_//. 

A  workman,  forty-six  years  of  age,  felt  a  violent  pain  in  his  right 
forearm  as  he  attempted  to  lift  a  hea\y  bundle  of  hay  on  N()veml)er  4, 
1H97.  The  pain  was  accompanied  by  the  sensation  of  having  broken 
his  arm.  At  lirst  he  was  treated  in  a  surgical  clinic  for  muscular 
strain  ;  suljsequently,  in  another  clinic,  for  a  fracture  of  the  right  iilna. 
I  took  a  skiagraph  of  the  part  on  November  23,  1897. 

The  patient  \\as  a  rather  tall,  very  \  igorous  man  ;  he  gave  a  good 
family  history,  had  served  in  the  army,  and  had  ])reviously  been  in 
good  healtli.  He  had  never  been  injured  until  iHiXJ,  when,  in  lifting 
a  heavy  sack  of  corn  to  his  back,  he  sustained  a  fracture  of  the  left 
forearm. 

The  skiagraph  showed  an  vnnmited  fra<^ture  of  the  right  nlna  in  its 
lower  third ;  and  also  that  the  bones  were  developed  to  an  unusual  degree. 


FRACTURES  OF  THE  RADIUS.  295 

Fractures  of  the  shaft  are  usually  followed  by  muscular 
atrophy  and  by  slight  functional  disability  of  the  elbow- 
joint  and  wrist,  depending  on  the  displacement. 

The  fragments  may  be  so  far  displaced  as  to  come  into  con- 
tact with  the  shaft  of  the  radius,  thereby  limiting  mov^e- 
ments  of  rotation.  The  same  effect  is  produced  by  a 
like  displacement  of  the  fragments  of  the  radius  in  cases 
of  fracture  of  the  latter  bone.  The  insurance  allowance 
in  such  cases  is  estimated  at  from  33|^^  to  40^  for 
the  right  arm,  from  25^  to  30^  for  the  left,  or  even 
higher. 

If  both  ulna  and  radius  are  involved  in  the  fracture, 
the  four  fragments  may  in  very  rare  instances  become 
consolidated  at  a  point  of  connnon  convergence.  The 
case  cited  by  Helferich  in  his  "  Fractures  and  Disloca- 
tions "  is  very  instructive  in  regard  to  the  use  of  narrow 
splints,  which  are  likely  to  cause  too  great  a  degree  of 
compression. 

Fractures  of  the  head  of  the  radius  are  often  fol- 
lowed V)y  consideraljle  disj)lacement,  resulting  in  ankylosis 
of  the  joint. 

Fractures  of  the  shaft  of  the  radius,  usually  caused 
by  direct  violence,  are  met  with  in  comparatively  few 
cases.  The  subsequent  displacement,  due  to  action  of  the 
biceps,  increases  as  the  line  of  fracture  approaches  the 
upper  third  of  the  bone. 

The  prognosis  as  to  function  in  fractures  of  the  forearm 
involving  both  bones  is  unfavonil)le  if  there  is  any  con- 
siderable degree  of  displacement.  In  the  majority  of  such 
cases  pronation  and  supination  are  greatly  limited,  while 
flexion  and  extension  are  imperfectly  executed  in  certain 
respects,  interfering  very  decidedly  with  the  usefulness  of 
the  arm. 

The  functional  disability  is  greater  the  nearer  the  frac- 
ture lies  to  the  joint.  Fractures  of  both  bones  near  the 
Avrist-joint  are  likely  to  produce  marked  degrees  of  dis- 
placement and  to  be  very  slow  in  healing. 


296  DISEASES  CAUSED  BY  ACCIDENTS. 

Case  of  fracture  of  the  loirerthinl  of  the  forearm  iri/h  c.rfrcme  dcf/rce  of 
disjylaeement  and  severe  functional  (JisaJtUitij. 

A  workman,  thirty-six  years  of  age,  fell,  striking  on  the  left  hand, 
in  October,  1893.  He  sustained  a  fracture  of  the  lower  third  of  the 
left  forearm,  Avhich  in  uniting  left  a  very  marked  conca^•ity  on  the 
radial  side.  The  arm  ^\as  refractured  in  the  hospital,  hut  the  opera- 
tion proved  unsucx-essful,  the  bones  returning  to  their  former  position, 
while  imion  took  yilaoe  very  slow  ly. 

1  examined  and  took  a  ski<igrai)h  of  the  patient  November  28,  1897. 
There  was  marked  deformity  of  the  forearm,  which  was  shortened  and 
atrophied.  The  hand  was  displaced  backward,  the  muscles  felt  soft 
and  were  much  atrophied;  the  temperature  of  the  part  was  de])ressed. 
The  forearm  presented  a  conca\"ity  on  the  radial  side.  The  left  hand 
could  exert  but  very  little  pressure;  the  elbow-joint  ])ermitted  i)rona- 
tion  and  supination  to  a  normal  degree,  but  the  mobility  of  the  wrist 
was  greatly  restricted.  The  last  three  lingers  were  held  slightly 
flexed,  but  could  be  closed.  The  patient  was  allowed  40%  insurance 
allowance. 

Case  of  fracture  of  the  lower  third  of  the  left  forearm.      (Fig.  35. ) 

The  accompanying  figure  illustrates  a  case  analogous  to  the  one  just 
descriljed. 

A  mason,  thirty-seven  years  of  age,  fell  from  a  scaffolding  on 
August  31,  1893,  sustaining  the  injury  previously  mentioned.  He 
was  treated  in  the  hospital. 

I  examined  and  took  a  skiagraph  of  the  jiaticnt  on  March  '22,  1898. 
I  found  the  functional  jx^wer  of  the  aiMii  considerably  diminished; 
the  muscles  of  the  whole  arm,  including  the  hand,  were  greatly' 
atroiihied.  It  was  shortened  by  three  centimeters  and  its  strength 
was  diminished  by  three-fourths.  He  was  at  first  allowed  Hi'/c  insur- 
ance allowance;  it  was  later  reduced  to  40%,  at  A\hich  rate  it  has  been 
continued  up  to  the  present  time. 

The  uiifavoi'al)le  results  as  regard  pronation  and  supi- 
nation which  are  seen  in  cases  of  fracture  accompanied  by 
marked  displacement  of  the  fraoinents  have  already  l)een 
mentioned.  Functional  j)ower  may  in  other  cases  be  im- 
paired in  cons(>qucnce  of  pscudo-arthrosis  and  ischemic 
muscular  paralysis. 

Pseudo-arthrosis  causes  grave  functional  disal)ility.  It 
usually  renders  movements  demanding  tlie  exhibition  of 
much  strength  out  of  the  ([uestion,  although  a  few  instances 
are  on  record  in  which  considerable  power  was  dis- 
played some  time  after  injury.  Patients  are  frequently 
obliged  to  wear  a  fi.\ation-bandag(!  aroinid  the  forearm  in 
order  to  use  the  hand  even  for  ordinary  piirj)oses.  The 
lo^ver  fragment  is  apt  to   become  greatly  atrophied,  tlie 


Fig.  35. 


298  DISEASES  CAUSED  BY  ACCIDENTS. 

atrophy  involving  not  only  the  nuiseles  and  adipose  tissue, 
but  extending  in  the  course  of  time  to  the  bone  as  well. 
In  some  cases  union  may  finally  be  established,  even  when 
a  considerable  period  has  elapsed  after  injury  ;  I  have 
known  it  to  occur  as  long  as  two  years  afterward. 

The  development  of  a  new  joint  is  seldom  favorable  to 
functional  power  as  far  as  movements  of  rotation  are 
concerned. 

Ischemic  nuiscnlar  paralysis  is  a  paralysis  of  the  mus- 
cles of  the  forearm  due  to  compression  from  too  firm  a 
bandage.  Unless  treated  early,  the  condition  is  a  very 
difficult  one  to  overcome. 

Typical  Fractures  of  the  Radius. — 

My  pereonal  observation  lias  covered  14()  cases  of  these  fractures. 

In  examining  the  radius  with  reference  to  reunited  fractures  it  is 
advLsahle  to  begin  ))y  inspection,  first  \vith  the  arms  lianging  at  the 
side,  then  with  the  thund)s  of  l)otli  liands  placed  side  bv  side.  The 
appearance  of  the  extensor  and  flexor  surfaces  should  Ije  carefully 
noted,  also  the  profile  of  the  part.  In  practising  pal])ation  the  lower 
fragment,  the  head  of  the  ulna,  the  capsule  of  the  joint,  the  caqml 
bones,  etc.,  should  be  thoroughly  gone  over.  All  the  joints  of  the 
arm  should  be  test'cd  as  to  their  functional  ability. 

We  are  justified  in  using  the  term  typical  fractures  of 
the  radius  in  describing  the  fractures  of  the  lower  end  of 
the  l)<)ne,  not  only  because  of  the  frecjuency  of  their  occur- 
rence, but  also  because  they  almo.st  all  arise  under  similar 
circumstances  and  present  characteristic  appearances,  both 
before  and  after  consolidation,  in  s})ite  of  the  great  di- 
versity of  their  forms.  Many  cases  of  so-called  s])rains 
of  the  wrist  are  really  fractures  of  this  type.  The  two 
lesions  are,  in  fiu^t,  frequently  produced  in  the  same  man- 
ner,— by  a  fall  on  the  hand, — so  tliat  it  would  not  seem 
inappr<»])riate  to  speak  of  fractures  of  the  kind  imder  dis- 
cussion as  "sprain-fractures." 

The  foi'ce  of  the  fall  which  ])roduces  them  is  not  neces- 
sarily ap[)lied  to  the  palm  of  the  hand  ;  they  may  equally 
well  l)e  caused  by  a  fall  on  the  back  of  the  hand  or  on 
the  clenched   hand.     I   have   also  known  cases  to  occur 


FRACTURES  OF  THE  RADIUS.  299 

from  overextension  of  the  wrist  when  unloading  heavy 
beams,  or  even  as  a  result  of  a  fall  or  blow  on  the  lower 
end  of  the  ulna.  The  ulna  in  some  instances  remained 
intact,  while  in  others  the  styloid  process  was  broken  oif. 
The  line  of  fracture  varies  with  the  cause  which  produces 
it  and  the  manner  in  which  the  force  is  applied.  It  is 
important  to  ascertain  all  the  facts  bearing  on  this  jjoint 
in  order  to  gain  a  clear  understanding  of  the  subsequent 
displacement  and  fnnctional  disability,  ^^'hen  the  line  of 
fracture  runs  transversely,  as  it  does  when  the  fracture  is 
caused  by  a  fall  on  the  outstretched  hand,  the  lower  frag- 
ment is  almost  invarialjly  disj)laced  backward,  while  it  is 
usually  displaced  forward  in  case  of  falls  on  the  dorsum 
of  the  hand. 

Union  may  be  established  within  the  first  week  or 
two,  or  may  require  three  or  four  weeks'  time.  In 
one  case  a  skiagraph  taken  three  weeks  after  the  injury 
occurred  showed  precisely  the  same  condition  as  had  ex- 
isted on  the  fourth  day.  It  does  not  do,  therefore,  to 
maintain  a  fixation-bandage  for  the  same  length  of  time  in 
all  cases. 

The  symptoms  of  typical  fractures  of  the  radius  after 
union  is  established  are  as  follows  : 

The  wrist  appears  broader  and  thicker  than  normal,  and 
the  head  of  the  ulna  is  considerably  displaced  to  the  side. 
The  hand  is  displaced  to  the  radial  side,  while  the  fingers 
often  point  more  to  the  ulnar  side.  (This  is  probably  often 
due  to  the  bandage.)  In  case  of  backward  displacement 
of  the  lower  fragment  the  latter  shows  as  a  rounded 
prominence  on  the  posterior  aspect  of  the  forearm  close  to 
the  wrist ;  above  the  j^rominence  there  is  a  hollow.  Close 
to  the  wrist  on  tiie  flexor  surface  of  the  forearm  the  soft 
parts  (the  ])ronator  (piadratns  mnsde  and  flexor  tendons) 
project  in  the  form  of  a  soft  tnmor.  This  prominence  of 
the  soft  parts  of  the  flexor  surfiice  is  a  regular  accompani- 
ment of  the  cases  caused  by  a  fall  on  the  palm  of  the  hand, 
but  is  not  seen  in  those  caused  by  a  fall  on  the  dorsum  of 


300  DISEASES   CAUSED  BY  ACCIDENTS. 

the  luiml.  The  shaft  of  the  radius  is  displaced,  as  a  rule, 
being  rotated  outward  by  the  muscles  attached  to  the  ex- 
ternal condyle  of  the  humerus  and  the  external  condyloid 
ridge.  Occasionally,  however,  the  shaft  is  rotated  inward. 
In  conse(|uence  of  this  disi)lacement  of  the  shaft  of  the 
radius  the  radius  and  ulna  cross  each  other,  either  above 
or  below  the  normal  point.  The  displacement  of  the  bone 
of  course  involves  a  similar  change  of  position  of  the 
muscles  surrounding  it,  as  is  shown  l)y  a  marked  dejires- 
sion  on  the  radial  side  of  the  forearm  in  its  lower  third, 
due  to  the  outward  displacement  of  the  point  of  insertion 
of  the  tendon  of  the  supinator  longus.  Partial  disloca- 
tions, varying  in  degree,  are  seen  in  both  the  superior  and 
inferior  radio-ulnar  joints,  and  in  case  of  the  latter  the 
dislocation  may  even  l)e  a  com])lete  one.  'J'lie  forearm  also 
very  frequently  a])pears  shortened.  In  the  majority  of 
cases  the  styloid  process  of  the  ulna  is  broken  oflp  and  the 
capsule  of  the  wrist-joint  is  swollen.  The  muscles  of  the 
forearm  and  hand  show  signs  of  atro])hy,  and  those  of  the 
upper  extremity  are  often  similarly  affected,  especially  the 
Inceps.  The  atro|)hy  of  the  biceps — which  is  due  to  the 
displacement  of  the  shaft  of  the  radius  and  the  restriction 
of  sujiination — diminishes  its  power  as  a  flexor  of  the 
elbow-joint.  The  elbow-joint  is  apt  to  be  held  flexed  at 
first,  allowing  neither  complete  flexion  nor  com})lete  exten- 
sion. Abduction  of  the  arm  is  also  likely  to  be  somcAvhat 
restricted.  In  some  cases  there  is  paralysis  of  the  parts 
sup])lied  by  the  nuisculos})iral,  median,  or  ulnar  nerves. 

The  bones  of  the  carpus  usually  escape  injury  ;  if  not, 
the  scaphoid  is  the  one  most  likely  to  be  involved.  The 
lesion  usually  takes  the  form  of  a  fracture  ;  occasionally, 
however,  the  scaphoid  is  dislocated  or  is  driven  into  the 
cancellous  tissue  of  the  radius. 

The  relation  between  the  arti(;ular  surface  of  the  radius 
and  the  carpus  is,  on  the  other  hand,  never  normal  in 
these  cases,  and  the  ligaments  of  the  carpus  are  always 
stretched  and  loosened.     This  results  in  imperfect  closure 


Fig. 


302  DISEASES  CAUSED  BY  ACCIDENTS. 

and  weakness  of  the  hand,  whicli  are  noticeable  symptoms 
of  the  recent  injnry,  and  sometimes  persist  for  a  long 
time. 

The  range  of  motion  at  the  wrist  is  considerably  dimin- 
ished, and  pronation  and  supination  are  restricted  in 
almost  all  cases. 

The  treatment  of  the  foregoing  condition  consists  of 
massage  and  passive  motion  and  of  gymnastic  exercises 
for  the  ])urpose  of  overcoming  the  displacem{>nt  and  anky- 
losis. Traction  made  with  increasing  weights  and  rotatory 
movements  are  very  beneficial,  while  electricity  should  be 
employed  for  the  paralysis. 

As  far  as  duration  of  treatment  is  concerned,  the  ])arts 
may  within  a  few  weeks  regain  as  much  functional  power 
as  can  be  hoped  for  at  all,  or  the  course  of  exercises,  etc., 
may  need  to  be  kept  up  for  months,  or  even  for  one  or  two 
years. 

Incapacity  for  self-support,  which  is  proportionate  to 
functional  disability,  varies  from  10^,  15/^,  or  20^  in 
light  cases,  to  bOfo,  QOfo,  or  even  70  fc  in  serious  ones. 
To  the  latter  class  belong  the  cases  of  loose-jointedness  due 
to  extensive  laceration  of  the  capsule  of  the  wrist-joint. 

As  already  stated,  dislocation  or  snl)luxation  of  the 
inferior  radio-ulnar  joint  is  a  very  frequent  complication  of 
typical  fractures  of  the  radius. 

The  styloid  process  of  the  ulna  is  occasionally  rotated 
so  as  to  be  directed  forward  or  l)ackward,  and  th(!  whole 
lower  end  of  the  ulna  may  be  found  al)nornK(lly  movable. 

Cnse  of  reunited  tifpieal  fracture  of  the  r<((lim  fottowed  by  perfeet  recov- 
ery.    (Fig.  36,  p.  301.)     " 

Tlie  subject  of  the  acoompanyiuf;  skiagraph  was  a  workman,  forty 
years  of  age,  who,  wlien  pushing  a  handcart,  on  August  27,  1H98, 
struck  against  a  heap  of  stones,  causing  his  hand  to  be  violently  pressed 
backward.     He  Avas  at  first  treated  for  a  sprain  of  the  wrist. 

The  skiagraph  shows  the  fracture  of  the  radial  epiphysis,  completely 
reunited,  the  line  of  fractui'e  showing  lint  very  little.  Tlie  styloid 
process  of  the  ulna  is  seen  to  be  broken  off,  and  the  ulna  is  slightly 
displaced  forward,  striking  against  the  semilunar  bone.  The  scaphoid 
is  evidently  not  in  normal  position. 


Fig.  37. 


304  DISEASES  CAUSED  BY  ACCIDENTS. 

At  the  time  I  examined  the  patient,  on  Se])tenil>er  (i,  1>^9S,  the 
movements  of  the  Avrist-joint  were  considerably  limited,  and  the  Ihi- 
gers  eonld  not  be  completely  closed. 

Indenniity  was  not  reipiired  in  this  case,  as  tlie  patient  made  a  com- 
plete recovery  before  the  beginning  of  the  fourteenth  week,  the  time 
when  insurance  is  first  paid. 

Crtse  of  typical  fracture  of  the  Uft  radius.  (Fig.  37,  p.  303),  result iug 
in  partial  recovery. 

A  carpenter,  forty -eight  years  of  age,  fell  from  a  roof,  on  November 
15,  1897,  landing  on  a  heap  of  siind,  with  his  left  hand  extended. 

I  examined  and  took  a  skiagraph  of  the  patient  on  No\"ember  25, 
1897.  The  fracture  is  shown  in  the  accompanying  illustration.  The 
forearm,  wrist,  and  fingers  were  greatly  swollen  ;  the  fingers  could  not 
be  closed,  and  the  deformity  was  extremely  well  marked.  The  injured 
part  was  placed  in  temporary  plaster  jjandages,  and  was  treated  also 
by  massage,  steam  baths,  and  later  on  by  exercises.  The  deformity 
was  overcome  by  refracture  of  the  boUe. 

The  patient  was  discharged  on  May  21,  1)^98,  a\  ith  an  insurance 
allowance  of  30^^. 

The  index-finger  and  middle  finger  had  been  mutilated  in  an  earlier 
accident  ;  otherwise  the  hand  coidd  be  completely  clo^^ed  ;  the  grip, 
however,  was  still  weak.  Six  months  later  the  insurance  allowance 
was  reduced  to  20%,  at  which  rate  it  has  continued. 

Case  of  ii/j)ical  fracture  of  the  radius,  accompanied  hy  dislocation  of 
the  inferior  radio-ulnar  joint. 

A  workman,  thirtv-one  years,  of  age,  fell  from  a  ladder  on  August 
2G,  1898.      (Fig.  38,  p.  305.') 

The  skiagraph  taken  on  October  10,  1898,  showed  union  to  liavc 
taken  place.  The  wrist,  however,  was  still  swollen,  and  its  mobility 
was  restricted.  The  patient  \vas  still  iinal)le  to  close  the  hand,  which 
was  very  weak.     The  hea<l  of  the  ulna  \\as  ^■ery  freely-  nujvalde. 

The  skiagraph  shows  the  line  of  fracture  in  the  radial  epiphysis,  the 
dislocation  of  the  inferior  radio-ulnar  joint,  the  displacement  of  the 
bones  of  the  carpus,  and  the  disjdaeement  of  the  hand  to  the  radial 
side.  When  discharged,  after  consideral)le  imi)ro\ement  had  taken 
place,  the  patient  was  conceded  an  insurance  allowance  of  30%. 


5.    INJURIES   AND   TRAUMATIC    DISEASES  OF  THE 
WRIST=JOINT. 

Comiderutions  as  to  Anatomy  and  Function. — The  mechanism  of  the 
wTist  is  rather  complicated,  normally  consisting  of  six  separate  joints 
or  combination  joints. 

1.  The  radi(X'ar])al  aiticulation, — the  wrist-joint  proper, — formed 
by  the  radius  alto\e  and  the  scaphoid  and  semilunar  bones  below. 
Flexion  and  extension  take  ])lace  in  this  joint. 

2.  The  inferior  radio-ulnar  articulation,  ])ermitting  of  the  movements 
of  pronation  and  sujunatiou,  constituting  the  rotation  of  the  wrist. 

3.  The  joint  between  the  pisiform  and  cuneiform  bones. 


Fig.  38. 


'><>()  DISEASES   CAUSED  BY  ACCIDENTS. 

4.  The  combination  joint  lietween  the  scaphoid,  seniilnnar,  cunei- 
form, unciform,  os  magnum,  trapezoid,  inner  surface  f)f  the  trapezium, 
and  the  bases  of  the  second  and  third  metacaipal  bones,  forming  the 
intercarpal  and  metacarpal  joints. 

5.  The  articulation  between  the  unciform  bone  and  the  bases  of  the 
fourth  and  tifth  metacarpal  Ijones. 

(!.  The  articulation  between  the  trapezium  and  first  metacarpal  bone. 

The  last-named  joint  ( reciprocal  reception )  is  always  entirely  sepa- 
rate from  the  others,  while  in  some  individuals  all  tlie  other  fi\e  joints 
may  be  in  communication  M'ith  one  another.  In  such  cases  we  have 
to  deal  with  two  joints,  or  rather  with  one  joint  and  one  combination 
joint.  The  communication  existiiig  between  these  fi\'e  joints  explains 
the  rapid  involvement  of  the  whole  wrist  in  some  cases  of  infection. 
A  similar  extension  of  infection  to  the  wrist  in  cases  of  injury  of  the 
joint  between  the  trapezium  and  first  metacarpal  l)one  is  to  lie  explained 
by  the  destruction  of  the  interosseous  ligament.  In  operating  for  the 
removal  of  the  thumb  and  first  metacarpal  bone,  injury  of  this  ligament 
should  l)e  carefully  avoided.  This  can  l)est  be  accomplislied  by  enter- 
ing the  joint  innnediately  below  the  insertion  of  the  tendon  of  the 
abductor  longiis  pollicis  (extensor  secundi  internodii  pollicis). 

The  fact  that  the  triangular  fibrocartilage  occasionally  i)resents  a  per- 
foration is  of  importance  in  dealing  with  injuries  and  diseases  of  the 
lower  radio-ulnar  joint. 

Another  point  to  be  borne  in  mind  is  the  occasional  existence  of  in- 
terosseous ligaments  between  the  joints  which  usually  intercommuni- 
cate, thus  increasing  the  number  of  separate  joints  in  the  wrist. 

The  strongest  ligament  of  the  wrist-joint  is  found  on  its  anterior 
surface;  posteriorly,  the  ligament  consists  of  separate  and  compara- 
tively weak  filirous  bauds  connecting  adjacent  bones.  When  the 
wrist-joint  becomes  filled  \\ith  a  fluid  exudate,  the  capsule  of  the  joint 
is  pressed  out  between  these  bands,  forming  the  so-called  ganglia  of 
the  wrist. 

In  their  passage  across  the  back  of  the  wrist  the  extensor  tendons 
are  retained  in  position  by  the  posterior  annular  ligament,  an  exten- 
sion of  the  posterior  fascia  of  the  forearm.  It  is  strengthened  by  some 
additional  fibers.  It  is  di\'ided,  as  a  rule,  into  seven  separate  com- 
partments for  the  various  tendons,  some  of  which  are  usually  inclosed 
in  a  common  synovial  meml)rane. 

The  wrist  is  capable  of  the  following  movements: 

1.  Flexion  (anteflexion). 

2.  Extension  (retroflexion). 

3.  Abduction  (movement  toward  the  radial  side,  radial  flexion). 

4.  Adduction  (movement  toward  the  ulnar  side,  ulnar  flexion). 

5.  Circumduction,  which  is  a  combination  of  the  four  previous 
movements. 

6.  Rotation  (pronation  and  supination)  in  the  inferior  radio-ulnar 
joint. 

Flexion,  extension,  abduction,  and  adduction  are  executed  in  the 
wrist-joint  proper — the  radiocarpal  articulation.  Flexion  and  exten- 
sion are  limited — in  addition  to  the  tension  of  the  ligaments — by  the 


AXAT03IV  OF  THE  ]\'IiIST.  307 

contact,  above  or  below,  between  the  radius  on  the  one  hand  and  the 
scaplioid  and  semilunar  on  the  other. 

Flexion  and  extension  take  place  ar(jinul  a  trans\ei-se  axis  with  very 
little  change  of  plane.  The  angle  to  wliich  these  movements  can  be 
carried  varies  greatly  in  dili'erent  individuals,  and  even  varies  as  to 
the  two  hands  in  tJie  same  indi^-idual.  According  to  the  measui'e- 
ments  that  1  have  taken  on  indi\iduals of  different  ages  and  in  various 
classes  of  society,  extension  is,  as  a  rule,  somewhat  more  limited  tlian 
flexion  ;  this  point,  ho\\e\er,  often  depends  upon  the  profession  of  the 
individual.  In  a  nund^er  of  roofers  who  were  expert  in  climl)ing  I 
found  the  angle  of  extension  to  exceed  that  of  flexion.  The  a\erage 
angle  of  extension  was  (iO  degrees,  carried  in  special  cases  to  from  8.") 
to  J)0  degrees;  the  average  angle  of  flexion  was  6oh  degrees;  its  extreme 
limit,  90  degrees. 

In  extreme  flexion  and  extension  the  wrist-Joint  proper  is  assisted 
by  the  joints  l)etween  the  two  rows  of  carpal  bones. 

The  axis  around  which  the  carpus  re\'olves  in  abduction  and  adduc- 
tion does  not  form  a  straight  line,  but,  on  the  contrary,  the  plane  of 
motion  almost  constantly  changes.  The  angle  of  aliduction  never 
equals  that  of  adduction,  tlie  former,  according  to  my  measurements, 
being  represented,  on  the  average,  liy  3:3]  degrees,  the  latter  ))y  nearly 
50  degrees.  The  change  in  the  plane  of  motion  increases  as  the  ex"- 
tremes  of  abduction  and  adduction  are  reached,  especially'  in  the  case 
of  adduction.  A  certain  degree  of  movement  occuis  at  the  same  time 
among  tlie  joints  Ijetween  the  carpal  l)ones,  the  scaphoid  taking  part  in 
adduction,  the  cuneiform  in  abduction.  It  is  not  ^jossible,  hoAvever,  to 
enter  into  a  discussion  of  these  points  liere. 

Pronation  and  supination  are  executed  in  the  superior  and  inferior 
radio-ulnar  articulations.  Although  limited  by  the  tension  of  liga- 
ments and  tendons,  the  angle  thus  ol)tained  may  equal  or  exceed  1^0 
degrees.  The  radius  during  this  movement  rotates  around  the  ulna. 
Duchenne  maintains  that  the  ulna  moves  simultaneously. 

Mobility  of  tlie  wrist  is  essential  to  Avorkers  employed  in  the  various 
branches  of  industry,  especially  to  those  A\hose  work  requires  them 
either  to  grasp  and  to  hold  heavy  articles,  while  directing  their  further 
progress  with  the  wrist-joint,  or  to  exert  pressure  on  the  hand.  Anky- 
losis of  the  Avrist-joint  following  fractures,  dislocations,  sprains,  and 
inflammatory  processes  causes  a  corresponding  degree  of  disability  for 
self-support  on  the  part  of  the  patient. 

StatMics. — In  addition  to  the  14G  ca.ses  of  typical  fracture  of  the 
radius,  my  material  includes  87  cases  of  injuiy  of  the  wrist-joint, 
observed  after  healing  took  place.  This  number  includes  11  cases  of 
injuries  due  to  contusion,  51  cases  of  sprain,  5  of  dislocation  of  the 
bones  of  the  carpus,  14  of  fracture  of  the  bones  of  the  carpus  or  of 
the  styloid  process  of  the  ulna  occurring  separately,  and  6  of  wounds. 

Sprains  of  the  Wrist=]oint. 

Sprains  of  the  wrist-joint  are  ;i  very  common  form  of 
injury.     If  in  describing  an   injury  of  the  wrist-joint  we 


308  DISEASES  CAUSED  BY  ACCIDENTS. 

apply  the  term  sprain  strictly  in  the  sense  of  its  definition 
in  the  first  part  of  this  book, — namely,  as  a  dislocation  of 
only  momentary  duration,  righting  itself  at  once, — we 
shall  be  obliged  to  exclude  a  number  of  other  injuries  of 
similar  etiology  which  are  often  covered  by  the  name  of 
sprain.  Under  ''  sprains "  we  find  typical  fractures 
of  the  radius,  fractures  and  dislocations  of  the  bones  of  the 
carpus,  dislocations  of  the  inferior  radio-ulnar  articulation, 
etc. 

True  sprains,  in  which  the  lesion  consists  only  of  a 
strain  or  slight  laceration  of  the  capsule  and  ligaments  of 
the  joint,  are" soon  cured  by  rest  of  the  part,  together  with 
compresses  and  massage,  although  frequently  the  joint 
remains  weak  and  the  capsule  continues  relaxed  for  some 
time. 

In  almost  all  cases  of  sprain  coming  under  my  observa- 
tion for  the  last  three  years  I  have,  by  the  aid  of  skia- 
graphs, discovered  a  dislocation  of  the  inferior  radio-ulnar 
joint. 

Dislocation  of  the  Radio=uInar  Joint. 

This  lesion,  which  is  not  at  all  uncommon,  is  usually 
caused  by  falling  on  the  hand  or  by  twisting  the  wrist 
in  liftinp:  or  settino-  down  heavy  burdens.  It  is  also 
frequently  seen  as  an  accompaniment  of  typical  fractures 
of  the  radius. 

AVhen  the  acute  swelling  and  inflammation  have  sub- 
sided, leaving  the  joint-capsule  somewhat  thickened,  the 
wrist  appears  broader  than  normal,  or,  to  speak  more 
accurately,  the  transverse  diameter  of  the  lower  extremities 
of  the  radius  and  ulna  is  increased.  The  head  of  the  ulna 
is  usually  more  moval)le  than  that  of  the  normal  wrist ; 
the  strength  of  the  hand  is  diminished,  and  the  patient  is 
conscious  of  weakness  of  the  wa'ist-joint,  wdiich  is  some- 
what relieved  by  wearing  a  bandage  around  it.  Move- 
ment of  the  wrist  is  in  most  (tases  painful  rather  than 
restricted.     Pronation   and    supination   are   usually  well 


DISLOCATIONS  AT  THE  WRIST.  309 

preserved,  but  are  apt  to  cause  pain.  The  muscles  of  the 
forearm  are  but  slightly  aifectcd,  though  those  on  the 
ulnar  side  may  show  signs  of  atrophy.  By  the  aid  of  a 
skiagrapli  we  can  demonstrate  the  complete  dislocation  of 
the  inferior  radio-ulnar  joint,  and  in  a  number  of  cases  we 
also  find  that  the  head  of  the  ulna  is  rotated  so  that 
the  styloid  process  points  directly  forward  or  backward. 
Sometimes  the  head  of  the  ulna  is  displaced  upward  or 
downward,  indicating,  of  course,  more  or  less  laceration 
of  the  inferior  radio-ulnar  ligaments.  This  leads  to  a 
secondary  displacement  of  the  elbow-joint,  which  is  usually, 
however,  of  slight  importance,  and  is  not  marked  by 
functional  disabilitv.  The  average  insurance  allowance 
is  20/,. 

Dislocation  of  the  Wrist=joint. 

Simple  dislocations  of  the  wrist-joint  are  rare.  The 
so-called  dislocation  usually  includes  a  fracture  of  the 
radius.  The  latter  is  accompanied  by  displacement  of  the 
lower  fragment,  together  with  the  whole  hand  ;  the  wrist- 
joint,  however,  remains  partly  dislocated.  A  similar 
subluxation  is  also  frequently  to  be  seen  as  a  result  of  a 
sprain.  In  cases  of  backward  dislocation  of  the  wrist-joint, 
which  are  usually  caused  by  the  overextension  incidental 
to  a  fall  on  the  hand,  the  hand  is  held  flexed  ;  the  bones 
of  the  carpus — the  scaphoid,  semilunar,  and  cuneiform — 
are  distinctly  pron)inent ;  movement  of  the  wrist-joint  is 
suspended,  and  the  hand  can  not  be  closed.  In  cases  of 
forward  dislocation  due  to  a  fall  on  the  dorsum  of  the  hand 
when  the  wrist  is  flexed,  tlie  lower  extremities  of  the  bones 
of  the  forearm  project  distinctly,  the  hand  is  flexed  and 
hangs  limj),  and  the  mobility  of  the  wrist  is  almost  com- 
pletely lost. 

The  foregoing  characteristic  symptoms  persist  until  the 
dislocation  is  reduced,  whicli  in  a  neglected  case  may  prove 
a  difficult  or  impossible  ])rocedure.  If  the  patient  is 
young  and  reduction  is  at  once  practised,  complete  recovery 


3 1 0  nisEA SES  r. i  uhed  b  y  a  cci dents. 

may  he  cxpceted.  In  a  case  oectiri'in^-  in  a  pu})il  in  a 
g;yniuasiiuii  wl'.o  was  practising-  <»ii  a  lioi'izoiital  bar,  im- 
mediate reduction  was  followed  by  a  permanently  good 
result. 

It  is  worthy  of  mention  that  subluxation  of  the  wrist 
is  seen  occasionally  as  a  result  of  special  work  in  indi- 
viduals employed  in  certain  branches  of  industry.  Made- 
lung  describes  a  case  of  this  kind  in  which  the  lesion  was 
attributed  to  the  strain  incidental  to  the  work  of  his  trade. 
(Cited  by  Thiem.) 


Dislocation  of  the  Bones  of  the  Carpus. 

A  dislocation  between  the  two  rows  of  the  carj)al  bones 
lias  been  observed  in  rare  instances,  the  usual  cause  being 
a  fall  on  the  hand.  Dislocation  of  one  of  the  carpal 
bones  alone  occurs  somewhat  less  infrequently.  The  dis- 
location may  be  the  only  lesion  present,  or  it  may  occur 
in  connection  with  other  lesions,  such  as  fractures  of  the 
radius  or  sprains  of  the  wrist-joint ;  it  may,  furthermore, 
be  partial  or  complete. 

Partial  dislocations  are  caused  by  the  violent  contact 
between  the  bones  incidental  to  a  fall  on  the  hand  or  by 
traction  in  endeavoring  to  free  the  hand  when  it  is  caught 
and  held  fast.  The  ligaments  connecting  the  carpal  l)ones 
are  more  or  less  torn  at  the  time  of  injury  ;  they  become 
lax  in  consequence,  and  allow  the  carpal  bones  to  become 
displaced.  The  bones  are  most  likely  to  be  displaced 
backward,  owing  to  the  weakness  of  the  posterior  liga- 
ments. In  most  cases  it  is  the  os  magnum  which  is  in- 
volved, and  which  can  be  seen  and  felt  projecting  back- 
ward. 

Partial  dislocations  of  the  carpal  bones  are  fre(|uently 
seen  subsequent  to  fractures  of  the  radius,  and  are  to  be 
explained,  as  a  rule,  by  the  strain  and  subsequent  laxness 
of  the  ligaments.  When  some  time  has  elapsed  after 
injury,  tlu;  displaced  carpal    bone  can  easily  be  mistaken 


DISLOCATIONS  OF  THE  OAF. PUS.  311 

for  a  o'anglion  ;  the  diagnosis  is,  liowever,  inadc  clear  by 
a  careful  examination. 

In  cases  of  complete  dislocation  the  scaphoid  is  the 
bone  most  frequently  involved.  In  a  case  occurring  in 
connection  with  a  fracture  of  the  radius  due  to  a  fall  on 
the  hand  I  found  the  scaj)hoid  impacted  in  the  substance 
of  the  radius.     (See  Plate  36.) 

I  have  seen  three  cases  of  backward  subluxation  of  the 
OS  magnum.  A|)art  from  the  tumor-like  j)rojection  on 
the  dorsum  of  the  hand,  tlu;  only  symptom  of  the  lesion 
was  a  temporary  weakness  of  the  hand. 

One  case  of  forward  dislocation  of  the  trapezium  has 
come  under  my  observation.  The  ball  of  the  thumb 
appeared  swollen  and  thickened  ;  the  thumb  was  some- 
what dis[)laced  forward  and  its  mobility  was  restricted. 
For  about  four  months  the  patient  was  unable  to  use  the 
hand  for  grasping  and  similar  movements. 

I  have  had  two  cases  of  dislocation  of  the  pisiform  bone 
occurring  as  the  sole  lesi<^n,  both  of  which  were  caused  by 
a  fall  on  the  hand.  Both  eases  had  been  diagnosed  as 
sprains  of  the  wrist.  The  pisiform  bone  was  displaced 
above  the  transverse  fold  which  runs  across  the  anterior 
surface  of  the  wrist  close  to  the  palm  of  the  hand.  In  one 
of  these  cases  four  months  had  elapsed  since  the  lesion 
occurred,  and  reduction  was  not  indicated.  Tlie  flexor 
carpi  idnaris  and  the  ball  of  the  little  finger  were  atrophied, 
and  adduction  of  the  wrist  was  limited  ;  there  was  also  a 
slight  loss  of  strength.  All  the  symptoms  com})letely  dis- 
aj)peared  within  three  months.  The  second  case  ccmcerned 
a  workman  whom  I  examined  six  weeks  after  the  injury, 
and  who  made  a  rapid  recovery. 

In  respect  to  the  rate  of  insurance  allowance,  the  reader 
is  referred  to  the  illustrative  cases. 

Lenibke,  in  the  "  Archiv  far  Uiifallheilknnde,"'  volume  iir, 
desc^ribes  aii  outward  dislocation  of  the  scaphoiil  bone.  Its  conca\'e 
surface  lay  against  the  apex  of  the  styloid  ])i-ocess  of  the  radius, 
to  which  it  had  become  united,  while  its  convex  surface  was  directed 


312 


DISEASES  CAUSED  BY  ACCIDENTS. 


outward.  The  trapezium  and  trajiezoid  were  thereliy  displaced  forward, 
togetlier  with  the  first  two  inetacarpal  l)ones  and  fingers.  The  senii- 
hmar,  cuneiform,  os  magnum,  and  unciform  were  all  fractin-ed.  Exten- 
sion of  the  wrist-joint  could  be  carried  to  an  angle  of  fifteen  degrees, 
but  flexion  was  altogether  susi)en(led.  Abduction  and  adduction  were 
reduced  by  one-lialf;  the  tliund)  was  limited  as  to  flexion;  otherwise 
the  movements  of  the  lingers  were  normal.  The  cause  of  injury  in 
this  case  was  direct  violence. 

Lembke  also  descrilied  a  case  of  backward  dislocation  of  the  semi- 
lunar which  likewise  accomjianied  a  fracture  of  the  radius.  The  case 
was  also  complicated  liy  fracture  oi  the  os  magnum  and  the  unciform. 

Dislocations  of  the  carpometacarpal  joints  arc  also 
extremely  rare  lesions,  with  the  exception  ot"  the  tirst 
carpometacarpal  joint,   in  which  dislocation  occurs  com- 


Fig.  39. 


paratively  often.  I  am  indebted  to  G.  Schiitz  for  two 
cases  of  dislocation  of  from  the  second  to  the  iiftli  and 
from  the  first  to  the  fourth  metacarpal  bones,  respectively. 
In  both  instances  the  lesion  was  caused  by  an  accident 
with  a  steam-press. 

In  these  cases  the  metacarpal  bone  is  invariably  disj)laccd 
backward,  and  the  appearance  of  the  hand  is  very  char- 
acteristic. The  base  of  the  metacarpal  bones  i)roject  dis- 
tinctly, and  the  movements  of  the  wrist-joint,  especially 
flexion  and  extension,  arc  t>;reatly  restricted.  The  fingers 
can  not  be  closed  at  all,  and  their  power  of  extension  is 
restricted. 


I 


FRACTURES  OF  THE  CARPUS.  313 

Case  of  forward  disJocation  of  the  first  metacarput  bone  at  the  metacarpo- 
phalamjeal  joint. 

A  mason,  t\vent\-t\vo  years  of  age,  accidentally  struck  his  right  hand 
with  a  hammer.  The  lesion  was  diagnosed  as  a  fracture  of  the  thumh. 
When  I  examined  tlie  patient,  on  October  15,  1898,  I  found  the  liall  of 
the  thumb  swollen  and  painful;  the  fingers  were  held  ilexed,  and  the 
thumb  could  be  only  slightly  moved.  A  skiagraph  showed  a  forward 
dislocation  of  the  head  of  the  first  metacarpal  bone. 

The  course  of  treatment  was  interrupted  a  few  weeks  later  by  the 
arrest  and  imprisonment  of  the  patient.  The  accompanying  illustra- 
tion shows  the  appearance  of  the  hand,  including  the  thickening  of  the 
ball  of  the  thumb. 

Crt.se  of  a  sprain  of  the  wrist-joint  accompanied  by  dislocation  of  th(  pisi- 
form bone. 

A  workman,  forty-nine  years  of  age,  fell  into  a  ditch  on  May  23, 
189G.  Among  other  injuries  he  sustained  a  sprain  of  the  right  wrist. 
The  skiagraph  showed  a  tyjucal  dislocation  of  the  inferior  radio- 
ulnar joint  and  upward  dislocation  of  the  pisiform  bone.  The  liead 
of  the  ulna  was  very  freely  movable;  the  forearm,  especially  on  its 
ulnar  aspect,  was  decidedly  atrophied,  as  were  also  the  ball  of  the  little 
finger  and,  in  part,  the  ball  of  the  thumb.  The  hand  had  lost  consid- 
erably in  strength.     Insurance  allowance,  20  % . 

Case  of  dislocation  of  the  pisiform  bone.,  due  to  a  fall  on  the  hand. 

A  mason,  forty -four  years  of  age,  fell  from  a  scaffolding  nine  feet 
high  on  June  24,  1892.  He  was  treated  for  some  time  for  a  sprain  of 
the  wrist.  "WTien  I  examined  him,  on  November  30,  1892,  I  found  the 
pisiform  bone  displaced  upward  above  the  transverse  fold  of  the  ^vrist. 
The  symptoms  in  this  case  were  exactlj^  similar  to  those  of  the  preced- 
ing one.  Insurance  allowance  at  firet,  20^  ;  six  months  later,  com- 
plete recovery. 

Case  of  suhliLxation  of  the  os  magnum  caused  by  a  blow  from  a  marble 
slab  which  fell  upon  the  hand. 

A  stone-mason,  forty-five  years  of  age,  was  trying  to  support  a 
marble  slab  with  l)oth  hands  when  it  slipped  and  fell  on  his  right 
hand,  holding  it  fast.  He  in\oluiitarily  made  an  effort  to  extricate 
the  hand.  The  accident  happened  on  jNIarch  9,  1899.  ^\^len  I  ex- 
amined him,  on  March  22d,  I  found  the  wrist  moderately  swollen  and 
distinctly  thickened  at  one  point  posteriorly.  The  skiagraph  that 
was  taken  showed  that  the  carpal  bones  were  placed  somewhat  un- 
usually far  apart.  Extension  was  somewhat  diminished  and  the  hand 
had  slightly  lost  in  strength.     No  insurance  allowance. 

Fractures  of  the  Bones  of  the  Carpus. 

The  carpal  bones  may  be  fractiiretl  by  direct  violence, 
as  when  the  wrist  is  crushed  under  falling  objects  or 
mangled  between  cog-wheels,  or  In'  indirect  violence,  such 
as  a  fall  on  the  hand.  Fractures  of  the  carpal  bones  not 
infrequently  accompany  fractures  of  the  radius. 


314  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  21. 

Case  of  Scar=keloid  on  the  Dorsum  of  the  Left  Hand. 

A  mason's  apprentice,  fifteen  years  of  age,  was  burned  on  the  left 
side  of  the  face  and  on  both  hands  by  an  explosion  of  gas.  Healing 
was  followed  by  keloid  growth  in  the  scars  on  both  face  and  hands, 
especially  marked  in  the  case  of  the  left  hand. 

The  colored  plate  sliows  the  scars  on  the  lower  part  of  the  forearm 
extending  down  to  the  midphalangeal  joints  of  from  the  second  to  the 
fifth  fingers  inclusive,  limiting  l)oth  the  flexion  and  extension  of  the 
wrist,  as  is  distinctly  to  be  seen  in  the  accompanying  illustrations. 
(Figs.  40  and  41.  )  The  patient  could  close  the  hand,  but  was  unable  to 
hold  anything.  Figure  40  shows  the  extension  of  the  hand,  which  was 
limited  to  an  angle  of  about  thirty-five  degrees  ;  in  this  position  the 
scar-tissue  was  thrown  into  folds  between  the  back  of  the  hand  and  the 
forearm.  In  figure  41  the  hand  is  flexed,  thereby  stretching  the  scrar. 
Flexion  was  limited  to  an  angle  of  twenty  degrees.  Insurance  allow- 
ance, 20  ^. 

The  bones  of  the  car})iis  are  not  exposed  to  extensive 
degrees  of  dis})lacement,  but  the  effect  on  finictional  power 
of  even  a  slight  disphicenient  which  only  a  practised  eye  can 
recognize  is  not  to  be  underestimated.  Trifling  elianges  of 
relation  between  the  bones  of  the  carpus  have  an  influence 
on  the  position  of  the  metacarpal  bones,  and  are  manifested 
also  in  certain  limitations  in  the  movements  of  the  fingers. 
There  may  be,  furthermore,  a  slight  subluxation  of  the 
radiocarpal  joint.  Occasionally,  the  metacarptd  bones  are 
involved  in  the  fracture  to  the  extent  of  being  notched  at 
their  bases  ;  they  may  also  be  displaced  forward  or  back- 
ward, and  in  rare  instances  ma}'  be  rotated  on  their  long 
axes.  Displacement  of  a  metacar[)al  bone  causes  tempor- 
arily a  certain  awkwardness  of  movement  in  the  corre- 
sponding finger. 

In  case  of  fracture  of  the  l)ones  of  the  car])us  without 
displacement,  functional  power  is  only  temporarily  im- 
paired, unless  the  injury  is  a  severe  one  involving  several 
bones,  as  when  the  wrist  is  crushed  or  mangled.  In  the 
latter  case  the  wrist  remains  permanently  and  completely 
ankylosed.  The  symptoms  which  I  had  the  o]i]X)rtunity 
to  observe  in  two  cases  of  fracture  of  the  trapezoid  were 


T(ih.:^i 


i.ith.A/ist  f-'-  RpidduiUl .  Miiiirh<ii 


SCABS  ON  THE  WBIST.  315 

restricted  movement  of  the  timnil),  sensitiveness  of  the 
ball  of  the  thumb  to  pressure,  moderate  swelling  of  the 
first  corpometaearpal  joint,  and  inability  on  the  part  of  the 
patient  to  grasp  an  artiele  with  any  power  or  to  maintain 
his  hold  on  it. 

Case  of  iDuotifed  fracfure  of  the  scaphoid. 

A  Avorknian,  thivty-fonr  years  of  ajje,  stuinbletl  over  a  beam  and  fell 
on  his  riglit  hand  on  January  IH,  lH9(j.  He  was  treated  for  a  sprain. 
Six  months  later  the  same  hand  was  caujilit  under  a  beam,  crushing 
the  wrist.  A  skiagraph  that  was  taken  a))out  eighteen  months  later 
showed  an  ununited  fracture  of  the  scaphoid.  The  wrist  has  remained 
swollen  posteriorly,  and  still  crepitates  distinctly  on  movement ;  the 
affected  part  is  considerably  weakened.  The  patient  wears  a  bandage 
arotind  his  wrist.     Insurance  allowance,  20%. 

Injuries  of  the  nerves  and  infectious  processes  consti- 
tute the  most  serious  complications  of  fractures  and  dislo- 
cations of  the  carpal  bones,  leading,  especially  in  case  of 
infection,  to  grave  functional  disability  of  the  wrist,  fre- 
quently of  a  permanent  nature. 

Simple  fractures  of  the  carpus,  Avhen  properly  treated, 
usually  unite  rajiidly  and  satisfactorily.  If  in  consequence 
of  a  mistaken  diagnosis  the  patient  is  permitted  to  resume 
work  too  soon,  the  prognosis  as  to  functional  power  may 
be  unfavorably  affected. 

Serious  cases  of  fracture,  es})ecially  when  involving 
several  bones,  invariably  lead  to  ankylosis. 

Aid<ylosis  of  the  wrist  not  only  affects  the  mobility  of 
that  joint,  but  also  prevents  the  fingers  from  closing 
normally. 

Insurance  allowance,  40^  for  the  right  hand,  30^  for 
the  left.  It  is  only  in  exceptional  cases  that  ankylosis  of 
the  wrist  can  fail  to  incapacitate  the  patient  more  or  less 
for  the  duties  of  his  trade.  A  case  of  this  kind  is  described 
under  plate  23. 

Scars  on  the  Wrist. 

If  the  mobility  of  the  wrist  is  affected  by  a  scar,  the 
working  capacity  of  the  patient  is  likely  to  be  diminished 
to    a    degree  corresponding  with    the  loss  of   functional 


316 


DISEASES  CAUSED  BY  ACCIDENTS. 


power.  The  further  the  scar  extends  across  the  wrist  and 
down  the  hand  toward  the  fingers,  either  on  the  pahn  or 
back  of  the  hand,  the  more  serious,  as  a  rule,  is  its  influence 


Fig.  40. 


Fig.  41. 


on  mobility.  A  scar-keloid,  for  instance,  extending  over 
the  wrist  may  seriously  disable  the  latter,  although  in  itself 
it   is  a   perfectly  healthy  joint.     Scars  adherent  to    the 


INJURIES  OF  THE  HAND.  317 

underlying  tissues,  especially  if  deeply  attached,  bring 
about  the  worst  results. 

Chronic  tenosynovitis  is  quite  fre([uently  observed  at 
the  wrist,  p-ivino-  rise  to  tenalt>ia  ere])itans,  of  which  crack- 
ling  sounds  on  movement  of  the  wrist,  sometimes  accom- 
panied by  pain,  are  among  the  characteristic  symptoms. 

Chronic  tenosynovitis  occurs  also  as  a  professional  dis- 
ease in  various  branches  of  industry,  being  met  with  in 
turners,  cabinet-makers,  locksmiths,  blacksmiths,  etc. 


6.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
HAND  AND  FINGERS. 

Function  of  the  Jlctdcarpal  Bones  find  Finf/ers. — The  five  metacarpal 
bones,  which  forjn  the  framework  of  the  hand  proper,  are  somewhat 
concave  anteriorly,  slii^litly  convex  jjosteriorly. 

The  hand  presents  t\\  o  snrfaces — an  anterior,  called  the  palm,  and 
a  posterior,  called  the  dorsum  or  back  of  the  hand. 

The  first  metacarpal  bone,  siipporting  the  ball  of  the  thumb,  dis- 
plays a  comparatively  Avide  range  of  motion,  the  mobility  of  the  other 
four  metacarpal  bones  being  extremely  limited.  Of  the  latter,  the 
fifth  is  somewhat  more  mo\able  than  the  others,  while  the  third  is 
practically  immovable.  In  respect  to  their  mobility,  the  fingers  jtre- 
sent  a  marked  contrast  to  the  corresijouding  metacarpal  l)ones. 

The  phalanges  are  distinguished  as  the  first  or  jnoximal  phalanx, 
the  second  or  midphalanx,  and  the  thml  or  distal  ])halanx,  while  the 
joints  of  the  fingers  are  known  as  the  metacarpophalangeal,  mid- 
phalangeal,  and  distal  phalangeal  joints,  respectively. 

The  metacarpophalangeal  joints  are  of  the  condyloid  variety,  allow- 
ing of  the  folloAving  movements: 

1.  Flexion,  which  c^an  be  carried  to  an  angle  of  90  degrees;  slightly 
higher  in  the  case  of  the  little  finger. 

2.  Extension.  This  movement  is  very  limited.  On  active  motion 
the  thumb  can  be  extended  to  an  angle  of  about  50  degrees;  the 
index-finger  to  about  80  degrees,  the  middle  finger  to  about  25  de- 
grees, while  in  case  of  the  fourth  and  fifth  fingers  there  is  no  power 
of  extension  worth  mentioning. 

3.  Lateral  movement,  abduction,  adduction  (limited),  and  spread- 
ing apart. 

4.  Rotation  (on  passive  motion). 

The  chief  agents  of  flexion  are  the  long  flexors  of  the  fingers,  the 
tendons  of  which  are  inserted  in  the  second  and  third  phalanges;  the 
interossei  which  are  attached  to  the  first  phalanges  acting  as  a  pulley, 
drawing  them  toward  the  middle  line  when  the  hand  is  to  be  closed, 
and  pulling  them  apart  when  it  is  opened. 

The  capsules  of  the  metacarpophalangeal  joints  are  very  thin  pos- 


318  DIHEA S ES  CA  USED  BY  A  CCI DENTS. 

teriorly,  and  are  protected  from  being  caught  between  the  bones  and 
from  the  injurious  effects  of  too  great  atmospheric  pressure  by  tlie  ex- 
tensor tendons,  wliich  form  the  dorsal  a])(jneurosis  and  are  attached  to 
the  capsule  over  the  joints.  Laterally,  the  capsules  are  reinforced  by 
the  lateral  ligaments,  which  are  put  on  the  stretch  when  the  fingers 
are  flexed,  and  \\  Inch  greatly  restrict  lateral  mo\  ement  of  the  fingers. 

The  movements  of  the  fingers,  especially  of  the  fointh  finger,  are 
further  restricted  by  the  tendinous  slips  connecting  the  extensor  ten- 
don of  the  fourth  finger  with  those  of  the  middle  and  little  fingers, 
resijectively.  On  the  posterior  aspect  of  the  \\rist-joint  the  synovial 
sheatl>  of  the  extensor  longiis  pollicis  is  frequently  found  to  connect 
with  those  of  the  extensf)r  carpi  radialis  longior  and  brevior,  which 
also  in  many  cases  connnunicate  with  each  other.  Opposite  the 
metacatijophalangeal  joints  the  tendons  of  the  extensor  muscles  of 
the  fingers  unite  with  those  of  the  lumbricales  and  interossei  pro- 
ceeding from  the  radial  and  ulnar  sides  of  the  hand,  to  form  a  broad 
aponeurosis,  which  covers  the  phalanges  posteriorly  and  is  attached 
to  the  capsules  of  the  metacarpophalangeal  joints.  As  it  passes 
along  the  posterior  surface  of  each  proximal  ijhalanx,  to  A\hich  it  is 
not  attached,  the  extensor  tendon,  which  forms  its  central  poition, 
divides  into  three  slips;  the  middle  slij)  is  inserted  at  the  midphalan- 
geal  joint,  while  the  two  lateral  s]ii)s,  in  connection  with  the  tendons 
of  the  lumltricales  and  interossei,  pass  further  down  the  finger,  to  be 
inserted  into  the  distal  phalangeal  joint.  Thus,  the  dorsal  ap(meurosis 
is  attached  to  all  three  phalangeal  joints.  On  the  palmar  side  there  is 
a  communication  Ijetween  the  synovial  sheaths  of  tlie  tendons  of  the 
thuml)  and  little  finger,  as  is  demonsti'ated  ])y  the  I'apid  spread  of 
infection  from  one  tendon  to  the  other  when  either  is  involved.  [These 
tendons  are  usually  stated  to  communicate  through  the  general  sheath 
to  which  they  extend. — Ed.] 

The  palm  of  the  hand  provides  a  receptacle  for  the  objects  that  are 
seized  and  held  by  the  fingers,  or,  rather,  by  the  fingers  and  meta- 
carpal bones  on  one  side  and  the  thumb  on  the  other,  like  a  pair  of 
tongs.  The  ball  of  the  tlunnl)  and  that  of  the  little  finger  also  act  as 
opposing  forces  in  the  i)rocess  of  grasping  an  object  with  the  hand. 

Normally,  when  the  hand  is  coni]>letely  closed  in  a  fist,  the  fingers 
are  turned  under  in  the  palm  of  the  hand;  if,  howe\er,  the  distal 
phalanges  are  ankylosed,  they  lie  with  their  flexor  surfaces  against  the 
palm  of  the  hand.  In  grasping  an  article  tightly  the  distal  phalanges 
are  pressed  firmly  against  the  palm  of  the  hand  by  the  other  phalanges, 
especially  by  the  middle  ones,  the  wrist  Ijeing  held  retroflexed. 

"While  rough  work  develoi)s  the  strength  of  the  hand  and  fingers, 
skill  of  movement  and  a  sensitive  toucli  are  reipiired  for  the  perform- 
ance of  more  delicate  tasks.  In  either  case  it  is  necessary  that  the 
whole  mechanism  (jf  the  hand  should  be  in  perfect  order,  a  condition 
with  which  injuries  and  diseases  of  the  hand  and  fingers  are  not  com- 
patible. 


CONTUSIONS  OF  THE  HAND.  319 

Statisfirs. — This  cliapter  is  ])as('(l  on  an  experience  \vitii  7;21 
injuries  of  the  hand  and  lingers,  classitied  as  follows  : 

Injuries  due  to  contusion 222 

Crushing  and  mangling        97 

Ordinary  fractures 84 

Fractures  due  to  crushing  of  the  part 67 

Dislocations  and  sprains 55 

Incised  wounds 85 

Punctured  wounds 18 

Lacerated  wounds  caused  by  nails  and  splinters     71 

Burns 21 

Frost-bite 1 

721 

Cellulitis 78 

The  separate  fingers  were  involved  as  follows  : 

Thumb 149  (right  side,  80;  leftside,  69) 

Index-finger  ...  147  (  "  "  66  "  "  81) 
Middle  finger  .  .  172  (  "  "  73  "  "  99) 
Fourth  finger  .  .  129  (  "  "  54  "  "  75) 
Little  finger  .  .  .  80  (  "  "34  "  "  46) 
According  to  this  table,  the  fingers  of  the  left  hand  are  more  fre- 
quently involved  than  those  of  the  right. 

Among  the  total  of  677  injuries  of  the  fingers,  the  metacariial  bones 
were  involved  in  a  large  number  of  the  cases. 

The  hands  are  especially  exposed  to  injiirv  in  every 
department  of  industry,  hence  in  statistical  tables  based 
on  the  relative  frequency  of  injuries  in  ditierent  parts  of 
the  body  they  usually  stand  highest. 

Injuries  of  the  Hand  Due  to  Contusion. 

These  injuries  occur  when  the  hand  is  hit  by  an  object 
falling  from  a  height,  such  as  a  stone  or  a  piece  of  wood 
or  iron,  or  by  objects  falling  against  the  hand,  or  by  blows 
from  a  hammer,  etc.  If  tlie  force  is  applied  to  the  back 
of  the  hand,  the  injury  is  very  likely  to  consist  of  a  simple 
or  compound  fracture  of  the  metacarpal  bones.  Simple 
contusions  involving  the  hand  or  fingers  usually  heal 
rapidly  and  completely. 

There  is  one  peculiar  injury  of  the  contusion  class  in- 
volving the  ])all  of  the  thumb.  This  becomes  the  seat  of 
an  inflammation,  which  may  run  a  severe  course,  develop- 
ing into  a  cellulitis  and  rapidly  extending  up  the  hand  and 


320  DISEASES   CAUSED  BY  ACCIDENTS. 

arm.  Such  an  inflammation  of  the  left  thumb  is  most  fre- 
quently seen  in  masons  after  vigorous  and  long-continued 
counterpressure  on  the  ball  of  the  thuml)  in  the  process  of 
chip])ing  unusually  hard  stones.  The  lesion  occurs  in  the 
ball  of  the  right  thumb  as  a  result  of  similar  causes,  or  it  may 
involve  the  ])almar  fascia  in  the  middle  of  the  hand  in- 
stead. If  diffuse  suppuration  sets  in,  necessitating  frequent 
operation,  the  hand  is  usually  permanently  disabled  for  its 
customary  work. 

In  less  unfavorable  cases  the  inflammation  takes  a 
chronic  form,  the  fascia  becoming  irregularly  thickened 
and  contracted,  holding  the  proximal  phalanx  of  one  or 
more  fingers  in  a  position  of  flexion. 

Caxc  of  infldinmalion  of  Ihv  pnhnar  fascia  Jcadin;/  to  completp  stiffness 
of  the  hand  ((ini  finf/crs. 

A  ■svorkiuan,  tliirt,\ -four  yt'ars  of  aj;e,  (U'velopcd  an  inflamiuation 
of  the  palm  of  tlie  ri^lit  liand  ])ro(liK'etl  ))y  ]on,n-(H)ntimu'(l  imcssuic  of 
the  wooden  liandle  of  an  iron  pick  which  lie  had  used  in  chi])])in<i  hard 
stones.  On  the  day  follow in<i;  the  hand  was  swollen  ;  supj)iiration 
soon  set  in,  and  a  series  of  operations  was  recpiired. 

I  examined  him  on  Novend)er  7,  18^8,  and  found  the  wrist  and  lin- 
gers swollen.  The  ^vrist  jiresented  several  scars,  which  extended 
toward  hoth  the  \vd\m  and  the  hack  of  the  hand.  The  hand,  lingers, 
and  wrist  were  completely  immobilized. 

Mechanical  treatment  was  liegun,  and  was  continued  until  Septem- 
ber, 1889.  At  that  tinu^  the  lingers  could  Ijc  about  half  closed,  enab- 
ling the  patient  to  grasp  large  articles,  ))ut  not  to  hold  them.  Perma- 
nent insurance  allowance,  40%. 

Case  of  injlannnation  of  the  palm  of  the  fi(/ht  hand,  folloired  bi/  reeovery. 

A  carpenter,  fifty  years  of  age,  -worked  with  a  cro\vl)ar,  which  he 
held  braced  against  the  palm  of  the  right  hand,  on  November  6,  1891; 
on  the  following  day  the  hand  was  somewhat  swollen,  but  he  con- 
tinued to  work  until  No\ember  1  Ith,  altliough  the  hand  became  more 
and  more  painful.  Finally  he  entered  a  hospital,  where  a  number  of 
operations  were  ])erformed. 

He  came  under  my  care  on  .Tanuary  1,  1892.  The  hand  and  fingers 
were  at  that  time  swollen,  while  the  wrist  was  partly  encircled  by  a 
nund)er  of  scars,  some  of  them  deeply  attached.  Mo\ement  of  the 
fingers  was  restricted.  Massage,  local  baths,  and  exercises  were  pre- 
scribed. 

^^^aen  discharged,  on  .Tune  3,  1892,  tlie  patient  could  completely 
close  the  hand,  and  the  wrist  was  also  freely  movable.  The  only 
remaining  sym])tom  was  a  slight  weakness  of  the  hand.  Insiuimce 
allowance,  20%,  until  October  8,  1896,  when  functional  power  Avas 
completely  restorad. 


BURNS  OF  THE  HAND.  321 

When  the  hand  is  crusshcd  by  lidling  weights,  such  as 
heavy  beams,  stones,  iron  rails,  etc.,  or  by  being  run  over, 
the  injury  is  usually  complicated  by  simple  or  compound 
fractures.  The  worst  cases  of  the  kind  are  seen  when  the 
hand  is  caught  and  mangled  between  cog-wheels  or  be- 
tween hot  rollers  in  a  steam  laundry,  or  when  it  is 
crushed  by  extremely  heavy  weights.  In  such  cases  the 
bones  and  soft  parts  are  invariably  more  or  less  completely 
destroyed,  so  that  amputation  often  becomes  necessary. 
Relatively  favorable  results,  however,  are  sometimes  ob- 
tained even  after  these  severe  accidents. 

Burns  of  the  hand  and  fingers  are  of  common  occur- 
rence, and  have  a  great  variety  of  causes.  Thus,  the  hand 
may  be  carried  too  near  a  fire,  or  be  brought  in  contact 
with  a  hot  stove,  burning  coals,  steam,  etc.,  or  be  thrust 
into  hot  fluids,  caustics,  lye,  or  boiling  tar,  or  be  spattered 
by  hot  fluids,  or  the  l)urn  may  be  caused  by  the  explo- 
sion of  an  alcohol  or  kerosene  lamp,  etc. 

The  process  of  healing  is  frequently  protracted,  and 
results  in  cicatrices,  which  are  likely  to  be  very  pain- 
ful and  exceedingly  sensitive  to  pressure  for  a  long  time. 
Although,  as  a  rule,  superficial  and  nonadherent,  they  are 
very  likely  to  crack  open,  especially  in  cold  weather,  and 
when  they  extend  from  the  hand  on  to  the  fingers.  At- 
tempts to  close  the  hand  may  sometimes  suffice  to  cause 
the  scars  to  break  open.  The  scars  are  unfavorably 
affected  by  cold  weather  ;  the  hand  feels  cold  and  looks 
blue,  and  the  scars,  when  they  break  open,  heal  more 
slowly  than  at  other  seasons.  These  effects  are  not  diffi- 
cult to  understand,  if  we  consider  how  thin,  atrophic,  and 
contracted  such  scar-tissue  usually  is. 

The  use  of  ointments  is  often  beneficial,  and  in  winter 
vaselin  and  like  substances  should  frequently  be  applied, 
while  the  scar  should  also  be  protected  by  a  bandage  when 
the  ]xitient  is  at  work. 

The  working  capacity  of  the  patient  may  be  greatly 
diminished,  particularly  if  he  is  unable  to  hold  anythmg 
21 


322  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  22. 

Case  of  Trophoneurosis  of  the  Hand  Following  an  Acci= 
dent  in  Which  the  Median  and  Ulnar  Nerves  Were  Severed. 

A  sawyer,  thirty-two  yeiirss  of  at;e,  A\as  cut  across  tlie  left  forearm 
near  the  wrist  by  a  circular  saw  on  March  26,  lrt97.  The  wound  was 
treated  antiseptically  in  the  hosi)ital,  .hut  se\ere  sui)puration  set  in, 
necessitating  incision.  The  wound  healed  by  May  10th,  and  the 
patient  was  then  discharged  from  the  hospital.  He  received  treatment 
in  my  clinic  from  .July  2,  lrt97,  until  December  28,  Isy?. 

The  illustration  shows  the  scar  on  the  flex(jr  surface  of  the  forearm, 
reaching  to  its  inner  margin  and  slightly  constricting  the  latter.  The 
fingers  are  slightly  flexed,  as  if  holding  a  i>en.  Below  the  scar  the 
tissues  are  deeply  cyanosed  ;  thei'e  are  necrotic  ulcers  on  the  thumb 
and  on  the  tips  of  the  middle  and  fourth  lingers.  Tlie  i)art  is  extremely 
cold,  and  all  the  fingers  are  stiff.  Figure  2  shows  the  atroi)hy  of  the 
interossei  on  the  extensor  surface  of  the  hand.  Insurance  allowance, 
55  fc.     No  improvement. 


in  the  hand.  If  his  only  incapacity  is  the  occasional  crack- 
ing open  of  the  scar,  and  if  he  receives  fnll  pay  for  his 
work,  from  10  fo  to  20^  is  nsually  a  sufficient  allowance. 

Wounds  of  the  hands  are  met  witli  in  all  ])Ossible  forms 
and  varieties.  In  addition  to  classifying'  them  according 
to  their  clinical  appearance,  as  incised,  punctured,  lacerated, 
etc.,  a  classification  based  on  their  etiology  proves  both 
interesting  and  instructive,  acxpiainting  us  with  the  special 
dangers  of  the  various  branches  of  industry  and  enabliug 
us  to  make  more  effectual  ])rovision  for  their  |)reveution. 

Scars  on  the  extensor  surface  of  the  hand,  if  adherent 
to  the  extensor  tendons,  have  an  unfavoral)le  effect  on 
functional  power  by  interfering  with  flexion  of  the  fingers, 
and  finally,  by  their  retraction,  they  cause  the  fingers  to 
become  fixed  in  extension. 

Flexion  may  in  other  instances  l)e  prevented  by  scars 
that  are  adherent  to  the  metacarpal  bones.  This  is  the 
invariable  effect  of  adhesions  between  the  scar  and  the 
metacarj)ophalangeal  joint.  The  fingers  are  at  the  same 
time  held  slightly  extended,  while  the  head  of  the  first 
phalanx  is  displaced  forward. 


SCAES  OF  THE  HAND.  323 

Scars  extending  down  between  tlie  metacarpal  bones 
restrict  the  action  of  the  external  interossei,  as  is  evidenced 
by  diminished  abduction  of  the  tirst  phahmges  of  the 
affected  fingers.  If  nerves  are  involved  in  the  scars,  we 
usually  find  paralysis  of  the  fingers,  with  symptoms  of 
neuritis  or  neuralgia. 

The  ol)iect  of  treatment  is  to  loosen  the  scars  and  to 
restore  the  functional  power  of  the  fingers,  and  in  many 
cases  this  can  be  perfectly  accomplished  by  mechanical 
treatment  alone.  If  deeply  attached,  however,  the  scar 
should  be  freed  by  operation,  and  the  success  of  the  pro- 
cedure should  be  insured  by  subsequent  mechanical  treat- 
ment, which  should  be  begun  early. 

The  patient  is  incapacitated  for  work  in  proportion  to 
the  loss  of  functional  power  of  the  fingers. 

Scars  of  the  ])alm  of  the  hand  interfere  with  movement 
of  the  fingers  when  adherent  to  the  metacarpophalangeal 
joints.  Such  a  condition  is  not  always  the  result  of  an 
accident,  but  is  met  with  likewise  after  operations.  The 
scars,  for  instance,  consequent  upon  disarticulation  of  a 
'finger  (third  or  fourth  finger)  usually  show  a  strong  ten- 
dency to  retraction,  drawing  the  palm  of  the  hand  together 
like  a  boat,  the  more  so  if  much  of  the  metacarpal  bone  is 
removed.  The  two  fingers  thus  brought  side  by  side  by 
the  operation  show  an  inclination  to  remain  flexed  and  for 
their  tips  to  a])proximate  each  other  more  closely.  The 
other  fingers  follow  suit ;  the  hand  can  no  longer  be  prop- 
erly closed,  and  becomes  weak.  In  addition,  the  scars  of 
the  palm  are  particularly  sensitive  to  pressure,  and  fre- 
quently give  rise  to  violent  attacks  of  neuritis. 

A  prolonged  and  tiresome  course  of  treatment  may  be 
required,  calling  fi)r  the  exercise  of  considerable  patience. 
AVork  should  not  be  resumed  until  the  patient  can  use  the 
hand  for  grasping  and  liolding  purposes,  except  when  no 
further  improvement  can  be  looked  for.  The  incapacity 
for  self-su])port  is  estimated  according  to  the  loss  of  func- 
tional power. 


324  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  23. 

Case  of  Contracture  of  the  Wrist  in  Extension  Following 
Cellulitis.     Complete  ankylosis  of  wrist  and  fingers. 

A  hod -carrier,  forty  years  of  age,  in  his  twentieth  year  took  a 
nap  in  liis  noonday  rest,  sleeping  witli  his  right  hand  under  his  head. 
AVhen  he  awoke  he  was  conscious  of  pain  in  the  back  of  the  hand,  but 
continued  to  work  for  several  days  until  symptoms  of  fever  and  swell- 
ing of  the  hand  appeared. 

He  was  treated  in  the  hospital  for  three  months  ;  two  months  after 
this  he  recovered  some  use  of  the  hand,  and  although  the  -wTist  and 
fingers  have  remained  completely  stiff,  he  has  worked  as  Ijefore  as  a 
hod-c-arrier.  He  recei\es  no  insurance  allowance,  the  injury  not 
having  been  caused  by  an  accident  incidental  to  his  trade. 

Scars  occupying  the  center  of  the  hand  are  not  infre- 
quently adherent  to  the  palmar  fascia,  producing  a  contrac- 
tion of  the  proximal  phalanges  of  the  fingers.  This 
condition  does  not  necessarily  greatly  diminish  the  useful- 
ness of  the  hand,  however,  unless  the  scar  is  raised  above 
the  level  of  the  surrounding  skin,  in  which  case  the  pa- 
tient finds  it  difficult  to  take  a  firm  grasp  of  an  object, 
especially  if  of  a  hard  material.  In  addition,  the  scar  is 
constantly  exposed  to  injury. 

Scars  situated  on  the  ball  of  the  thumb  or  little  finger 
usually  cause  no  trouljle  unless  they  are  deeply  attached 
to  the  underlying  tis.sues. 

Sprains  of  the  Metacarpophalangeal  Joints. 

Sprains  of  these  joints  are  most  frequently  caused  by 
a  fall  on  the  closed  hand,  and  unless  complicated  by  frac- 

PLATE  -24. 
Case  of  Stiff  Hand  Following  Cellulitis. 

A  workman,  lifty-nine  years  of  age,  on  July  10,  1S91,  scratched  his 
right  thnml)  on  a  nail  projecting  from  a  pail.  He  was  treated  in  the 
hospital  for  the  cellulitis  tliat  followed,  a  number  of  incisions  being 
required. 

The  acconi])anying  illustration  shows  the  scar  of  tlie  original  wound 
of  the  thumb  and  tlie  scars  conse(|uent  upon  the  incisions  in  the  fore- 
arm, the  ))all  (if  the  thumb,  and  the  ball  of  the  little  finger.  It  also 
.slious  the  position  of  tlie  fingers  closed  u]K)n  the  palm,  rendering  the 
hand  entirely  useless.     Insui'ance  allowance,  60  ^/c 


Tah.:^4. 


LilA..  Anst  E  ReUhiwld.  Miuuchen. 


DISLOCATIONS  OF  THE  METACARPAL  BONES.      325 

ture,  they  usually  heal  without  auy  difficulty.  Inflamma- 
tion should  be  treated  by  compresses.  Stiffness  is  easily 
overcome  by  massage  and  passive  movements. 

Dislocations  of  the  Metacarpal  Bones. 

Complete  dislocation  at  the  metacarpophalangeal  joint 
occurs  with  relative  frequency  in  the  thumb,  but  is  seldom 
met  with  in  the  other  fingers.  If  a  dislocation  of  this 
joint  in  the  thumb  remains  unreduced,  it  leads  to  stiff- 
ness of  the  joint,  atrophy  of  the  nniscles  of  the  thumb, 
and  impairment  of  the  functional  power  of  the  hand.  The 
base  of  the  first  phalanx  projects  distinctly  backward, 
while  the  thumb  is  held  abducted.  It  is  well  known  that 
an  attempt  at  reduction  often  proves  unsuccessful ;  the 
capsule  of  the  joint  or  the  sesamoid  bone  at  that  jioint 
may  get  between  the  bones,  or  the  tend(in  of  the  flexor 
longus  pollicis  may  become  twisted  around  the  neck  of  the 
metacarpal  bone. 

Dislocations  of  the  metacarpophalangeal  joints  are  ac- 
com|)anied  by  laceration  of  the  capsules  and  ligaments, 
which  may  lead  to  a  subsequent  abnormal  position  of  the 
proximal  })halanges  of  the  affected  fingers,  even  after  suc- 
cessful reduction. 

Subluxation  of  the  phalanges  can  best  be  seen  l)y  letting 
the  patient  first  close  his  hand  and  then  open  it,  comjxu'ing 
it  meanwhile  with  the  normal  side. 

The  mobility  of  tlie  metacarpophalangeal  joint  may  be 
restricted  by  adhesions  or  may  be  abnormally  free  ;  in 
either  case  the  patient  is  unable  to  flex  the  finger  perfectly, 
and  it  often  appears  atrophied.  The  atropliy  gradually 
involves  the  internal  interossei,  and  possibly  the  lumbri- 
cales,  and  extends  in  the  course  of  time  to  the  other  mus- 
cles of  the  hand. 

After  the  dislocation  has  been  reduced  and  the  swelling- 
has  subsided,  but  very  little  after-treatment  is  called  for, 
as  a  rule,  except  in  cases  complicated  by  paralysis,  or 
when  there  is  ankylosis  of  the  metacarpophalangeal  joint, 


326  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATES  25  AND  26. 

Case  of  Atrophy  of  the  Forearm,  and  Partially  of  the  Arm, 
Following  an  Accident  to  the  Right  Hand  by  Which  the 
Index=finger  was  Wounded  and  Dislocated  at  the  Metacarpo= 
phalangeal  Joint  and  the  Distal  Phalanx  of  the  Thumb  Was 
Fractured. 

A  carpenter,  twenty -eight  jears  of  age,  snstained  the  foregoing 
injuries  on  July  29,  1898,  caused  by  a  beam  falling  on  his  right  hand 
and  his  involuntary  effort  to  extricate  his  hand  from  under  it.  The 
hand  was  dressed  innnediately. 

He  l)egan  a  course  of  treatment  in  my  clinic  on  August  23,  1898. 
On  the  i)alm  of  the  hand  near  tlie  Ijase  of  the  index-linger  there  was  a 
small  scar  ;  the  finger  was  sliglitly  displaced  at  the  metacaqioiihalan- 
geal  joint,  and  could  neither  be  flexed  nor  extended  completely. 
Movement  produced  crei)itation. 

The  atroi)hy  of  the  muscles  was  most  noticeable  when  the  hand  was 
compared  witli  the  opposite  side  and  when  it  was  tightly  closed.  The 
right  hand  could  not  be  so  tightly  closed  as  the  left.  There  was  but  a 
slight  difference  in  circumference  in  the  two  sides. 

Plate  2()  sliows  the  atrojthy  of  the  muscles  of  the  hand,  the  ball  of 
the  thund),  and  little  finger,  as  seen  from  the  palmar  surface.  The 
flexion  of  the  index-fiuger  is  imperfect.  Sometimes  the  finger  is 
slightlv  rotated  to  one  side  or  the  other. 


due  to  the  growth  of  adhesions  in  tlie  joint.  The  adhe- 
sions can  gradually  he  loosened  by  a  course  of  ])assive 
movements  and  mechanical  exercises.  It  is  very  imj)(>r- 
tant,  after  reducing  the  dislocation,  to  begin  the  finger- 
exercises  early,  before  the  bandage  is  removed.  Local  batlis, 
massage,  and  electricity  are  also  beneficial  in  completing 
the  cure.  If  the  hand  still  remains  weak,  or  its  mobility 
is  restricted, — which  in  the  case  of  the  third,  fourth,  and 
fifth  finoers  mav  be  due  to  adhesions  or  cicatricial  con- 
tractions  of  the  tendinous  sli])s  connecting  tliem, — the 
patient  may  be  somewhat  incapacitated  fi)r  work.  In 
such  cases  an  insurance  allowance  of  from  20^  to  30^ 
may  be  indicated. 

Fractures  of  the  Metacarpal  Bones. 

Fractures  of  the  metacarj)al    bones   may  occur  as  the 
result  of  direct  violence,  such  as   a  violent  blow  or  kick 


II 


Tab.:^j. 


Titf.l. 


LUh.  Arist  F.  ReichhoW.  Miiiulicn . 


Tab.'lh. 


Fig  P 


l.ith .  An.st  K  ReichiwUl.  Miinchen 


» 


^ 


Fig.  42. 


328  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  27. 

Atrophy  of  the  Muscles  of  the  Hand  Subsequent  to  a 
Fracture  of  the   Radius. 

A  glazier,  forty  years  of  age,  fell  from  a  ladder  from  a  height  of  six 
feet  on  August  17,  1898.  In  falling  he  tried  to  sa\'e  himself  with  the 
right  hand.  He  was  at  first  treated  for  a  sprain  of  the  wrist.  For  one 
week  ice-compresses  were  applied,  the  subsequent  treatment  consisting 
of  soapsud  baths  and  inunctions. 

I  examined  the  patient  on  Aiigust  31,  1898.  His  wrist  was  swollen 
and  appeared  broader  than  normal ;  the  lower  end  of  the  radius  was 
thickened,  the  enlargement  extending  down  to  the  carpal  Ijones.  The 
mobility  of  the  wrist  was  greatly  restricted;  flexion  and  abduction 
were  suspended;  retroflexion  and  adduction  coiild  l)e  carried  to  an 
angle  of  about  twenty  degrees.  The  fingers  could  l)e  slightly  moved, 
but  not  closed.  The  forearm  was  shortened  and  supinated.  There 
was  atrophy  of  the  hand,  forearm,  and  arm,  and  also  of  the  shoulder. 

The  accompanying  illustration  (Fig.  42)  shows  Ijotli  hands  and 
forearms  in  a  position  in  which  the  shortening  of  the  right  forearm, 
the  supination  of  the  elbow-joint,  the  atrophy  of  the  whole  arm,  in- 
cluding the  hand,  and  the  enlargement  of  the  wrist-joint  are  distinctly 
visible. 

The  skiagraph  (Fig.  43)  shows  the  impaction  of  the  scaphoid  in  the 
cancellous  tissue  of  the  radius,  slight  changes  in  the  relation  between 
the  carpal  bones,  and  the  disi)l;icement  of  tlie  liand. 

The  colored  plate  shows  a  distinct  atrophy  of  the  right  hand  on 
])oth  the  flexor  and  extenf5or  surfaces,  and  a  reddish-blue  discoloration 
of  the  skin  of  the  fingers  of  the  radial  side  of  the  hand,  including  the 
middle  finger  (radial  and  median  nerves).  The  temperature  of  this 
area  was  noticeably  depressed. 

The  patient  was  discharged  from  treatment  on  January  26,  1899, 
with  an  insurance  allowance  of  40%,  which  he  has  continued  to  re- 
ceive. He  works  ten  hours  a  day,  but  the  condition  here  described 
has  not  improved. 


on  the  back  of  the  hand,  or  a  blow  from  a  heavy  object 
in  falling  ;  or  as  the  result  of  indirect  violence,  as  in 
case  of  a  fall  on  the  closed  hand,  the  force  of  which 
is  met  by  the  first  phalan.v.  The  symptoms  after  union 
has  been  established  vary  considerably,  depending  on 
the  direction  of  the  line  of  fracture,  whether  transverse, 
oblique,  or  longitudinal,  and  on  whether  the  fracture 
involves  the  end  or  the  shaft  of  the  bone.  Displace- 
ment in  these  cases,  although  seldom  very  apparent  ex- 
ternally, is  sufficiently  marked  to  be  recognizable  and  to 


Tab.  2, 


'  ■!)■■-■ 


Fin  2 


•Jo. 


330  DISEASES  CAUSED  BY  ACCIDENTS. 

offer  an  explanation  of  the  symptoms  of  functional  disa- 
bility that  avo  manifested.  As  a  rule,  the  fragments  are 
displaced  backward,  forming  a  distinct  callous  convexity 
on  the  back  of  the  hand,  which  can  be  felt  if  not  seen. 
The  finger  appears  shortened  because  of  the  shortening  of 
the  metacarpal  bone  ;  frequently,  too,  the  lower  fragment 
of  the  latter  is  distinctly  rotated,  carrying  the  finger  with 
it.  When  the  head  of  the  metacarpal  bone  is  displaced 
toward  the  median  line,  the  corresponding  finger  is  often 
found  to  be  directed  away  from  it.  In  other  cases,  how- 
ever, the  finger  is  carried  toward  the  middle  line.  In 
addition,  the  base  of  the  bone  may  be  involved  in  the  de- 
formity by  being  displaced  forward,  backward,  or  even  to 
the  side.  The  lateral  displacement  of  one  metacarpal 
bone  leads  not  only  to  secondary  displacement  of  the  ad- 
jacent metacarpal  bones,  and  through  them  to  the  displace- 
ment of  the  whole  row,  but  affects  also  the  position  of  the 
carpal  bones  and  strains  the  ligament  of  the  carpus.  The 
general  displacement  thus  caused  is  manifested  by  dimin- 
ished mobility  and  weakness  of  the  fingers  and  wrist. 
Occasionally,  the  head  of  the  metacarpal  bone  is  dis- 
placed forward,  in  which  case  the  corresponding  finger 
can  not  be  properly  flexed  and  the  patient  is  unable  for 
some  time  afterward  t(j  maintain  his  grasp  on   an   article. 

Cane  of  rcii)} if cd  fracture  of  fJw  third  and  fourth  metacarpal  bones  and 
the  proximal  pJialaii.r  of  the  fifth  Jiin/er. 

A  niitson,  twenty-tive  years  of  afje,  was  injured  on  October  29,  1897, 
by  a  box  of  lime  fallinoj  upon  his  rij;ht  liand. 

^\^len  I  examined  liim,  on  Deccmljer  2,  1^97,  his  hand  was  still 
greatly  swollen  ;  the  tliird  and  fourth  metacarpal  bones  were  thickened 
posteriorly,  and  the  metacar])ophalan,iieal  joint  and  proximal  phalanx 
of  the  little  finger  were  considerably  thickened.  The  patient  was 
unable  to  flex  the  little  finger  at  all,  and  could  flex  the  others  only  very 
slightly.  The  skiagraph  (Fig.  44)  shows  the  fractures,  and  also  the 
displacement  of  the  third  and  fourth  metacarpal  bones  and  the  proxi- 
mal phalanx  of  the  fifth  finger. 

At  the  time  of  his  discharge,  on  June  22,  1898,  the  patient  was  able 
to  flex  the  index-,  middle,  and  fourth  fingers  so  that  they  almost 
touched  the  palm  of  the  hand,  while  the  fifth  finger  remained  about 
at  a  right  angle.     Insurance  allowance,  33^  %  ■ 


Fig.  44. 


Fig.  4.5. 


334  DISEASES  CAUSED  BY  ACCIDENTS. 

The  chief  cause  of  this  disability  is  the  pressure  ex- 
erted l)y  tlie  head  of  the  displaced  metacarpal  bone. 
AVhen,  after  fracture  of  the  head  or  base  of  the  bone,  ac- 
companied by  complete  lateral  dislocation,  the  bone  becomes 
fixed  in  this  ])Osition,  the  deformity  assumes  a  serious 
functional  import.  Sometimes  the  base  of  the  metacarpal 
bone  is  broken  oflp  and  driven  between  the  adjacent  meta- 
carpal bone  and  the  carj)us,  while  the  head  of  the  bone 
becomes  united  with  the  same  metacarpal  bone  on  its  oppo- 
site side.  As  a  natural  consequence  the  hand  is  l)roadcned 
and  the  fingers  are  considerably  displaced.  Deformities 
of  this  kind  are  seen  when  the  hand  is  crushed  and  man- 
gled between  cog-wheels,  etc. 

Case  of  deformiiy  of  the  hand  due  to  its  beititj  crushed  Ixiiceen  eog- 
whcels.     (Figs.  45  to  48,  pp.  332  to  335.) 

A  workman,  twenty-four  years  of  age,  was  injured  on  October  12, 
1897,  his  right  hand  1)eing  drawn  in  lietween  cog-wheels.  He  sustained 
the  fractures  tliat  are  distinctly  to  be  seen  in  the  skiagraph  (Fig.  45), 
which  also  shows  the  displacement  of  the  heads  of  the  bones  and  one 
of  the  fragments  of  the  fourth  metacarpal  bone  lying  upon  the  third 
metacari)al  bone.  It  was  necessary  to  remove  the  tiiird  and  fourth 
fingers.  In  the  accompanying  illustiations  (Figs.  4G  and  47)  the  ante- 
rior and  posterior  aspects  of  the  hand  are  disi)layed,  the  fingers  Ijcing 
extended  as  fiu"  as  i)Os.sil)le.  The  third  illustraticm  (Fig.  48}  shows  the 
limit  of  Hexion  of  the  lingers,  a  bit  of  pencil  being  held  between  the 
thumb  and  index-linger. 

Wlien  I  hrst  examined  the  patient,  on  January  li),  1898,  his  hand 
was  still  so  much  swollen  as  to  make  it  ai)])ear  like  a  tliick  and  shape- 
less mass  of  flesh,  i)ossessing  no  mobility  whatever.  Insurance  allow- 
ance at  the  time  of  discharge,  75^. 

The  cases  in  which  fracture  of  the  head  of  the  meta- 
carpal bone  involves  the  whole  joint,  in('lu<ling  the  corre- 
s])onding  articular  extremity  of  the  proximal  phalanx,  are 
usually  marked  by  ankylosis  of  the  mid])lKilanu('al  joint, 
as  well  as  of  the  metacarpophalangeal  joint  itself,  causing 
the  affected  finger  or  fingers,  if  several  are  involved,  to 
become  fixed  in  flexion,  thus  im])airing  the  usefulness  of 
the  whole  hand.  The  mobility  of  the  adjacent  finger  or, 
in  cases  involving  the  third  or  fourth  finger,  of  the  adjacent 
fingers,  is  secondarily  affected  as  a  rule,  so  that  the  hand 
can  be  only  partly  closed. 


Fig.  48. 


Fig.  49. 


336  DISEASES  CAUSED  BY  ACCIDENTS. 

The  following  points  deserve  special  mention  :  Fracture 
of  the  fir^t  metacarpal  bone  leads  to  primary  atrophy  of 
the  ball  of  the  thumi)  and  to  secondary  atrophy  of  the  ball 
of  the  little  finger,  the  reverse  holding  good  for  fractures 
of  the  fifth  metacarpal  bone.  Since,  in  addition,  there  is 
an  atrophy  of  the  interossei,  beginning  in  the  first  interos- 
seous muscle,  the  weakness  and  functional  disability  of  the 
whole  hand  are  easily  explained,  even  when  no  complica- 
tions exist  to  further  restrict  its  power. 

Fracture  of  the  second  metacarpal  bone  leads  to  primary 
atrophy  of  the  first,  second,  and  third  interossei,  limiting 
the  strength  of  flexion  of  the  index-finger,  and,  to  a  certain 
extent,  that  of  the  thumb  and  little  finger  as  well.  A 
similar  effect  is  produced  by  fracture  of  the  fifth  or  fourth 
metacarpal  bone,  and  in  case  of  fracture  of  the  third  the 
Aveakness  of  the  hand  is  a  particularly  well-marked  symp- 
tom, since  the  third  finger  is  normally  the  strongest. 

Treatment  is  chiefly  a  question  of  restoring  mobility  to 
the  affected  parts,  and  to  this  end  massage  and  exercise  of 
the  stiffened  joints  should  be  carried  out  with  great  regu- 
larity. Exercises  with  pulleys,  gradually  increasing  the 
weiglits,  should  be  begun  as  soon  as  the  power  of  flexion 
begins  to  return.  I^ocal  water-baths  and  steam-baths  are 
of  considerable  benefit. 

The  insurance  allowance  is  estimated  according  to  the 
functional  disability,  depending  on  the  number  of  joints 
involved,  and  on  the  degree  to  which  they  are  ankylosed. 
Complete  stiffness  of  a  metacarpophalangeal  joint  calls 
for  a  relatively  higher  rate  than  partial  stiff'ness. 

Case  of  tuberculosis  of  the  head  of  the  fieeond  metacarpnl  bone,  due  to 
metastasin.     (Fig.  49,  p.  385.) 

A  little  <;irl,  nine  years  of  a<ie,  turned  her  ankle  while  exercising 
in  a  gymnasinni,  and  was  treated  for  aliout  tiiree  niontlis  for  a  sprain. 
She  then  turned  the  same  ankle  again  in  crossing  the  street,  and  was 
thereafter  confined  to  bed.  The  ankle  became  more  and  more  swollen, 
and  an  abscess  formed,  which  left  se\'eral  fistulas. 

I  examined  the  patient  five  years  later.  She  was  then  a  thin, 
sickly,  and  undersized  child,  walking  on  two  crutches.  The  treat- 
ment that  I  instituted  consisted  of  careful  irrigation  of  the  fistulas, 


INJURIES  OF  THE  FINGERS.  337 

regulation  of  diet,  etc.  The  fistulas  healed  within  a  year,  but  the 
foot  remained  much  enlar<jed.  Since  that  time  the  child  has  felt  well, 
and  has  rai)idly  developed.  Two  yeare  later  a  fistula  appeared  spon- 
taneously on  the  palm  of  the  right  hand,  over  the  second  metacarpal 
hone.  There  was  no  ])ain  and  no  loss  of  functional  power.  The  skia- 
graph shows  with  great  distinctness  the  destraction  of  the  bone  by 
caries. 


INJURIES  OF  THE  FINGERS. 

Simple  contn.sions  of  the  fingers,  unaccompanied  by 
wounds  or  fractures,  hardly  call  for  discussion  here,  since 
they  cause  no  subsequent  functional  disability,  unless,  as 
occasionally  happens,  the  injury  leads  to  a  tenosynovitis, 
with  subsequent  contracture  of  the  tendon. 

Great  importance,  on  the  other  hand,  must  be  placed  on 
the  severe  injuries  that  occur  when  the  fingers  are  caught 
and  crushed  under  heavy  beams,  pieces  of  iron,  or. 
weights,  when  they  are  caught  and  compressed  between 
two  objects,  or  struck  by  a  stone,  by  a  hammer,  etc.  In 
such  cases  we  have  to  deal  either  with  simple  subcutaneous 
fractures  of  the  phalanges  (which  I  have  observed  almost 
invariably  after  these  injuries)  or  with  severe  comminuted 
fractures,  for  which  immediate  amputation  is  often  in- 
dicated. It  is  not  unusual  for  the  accident  itself  to  cause 
the  complete  or  partial  amputation  of  one  or  more  fingers. 
This  is  especially  likely  to  occur  when  the  hand  is  man- 
gled by  being  drawn  in  between  cog-wheels. 

In  respect  to  the  wounds  of  the  fingers  with  which  we 
have  to  deal,  it  will  suffice  to  mention  a  few  of  the  most 
important  varieties.  Incised  wounds  caused  by  sharp 
knives  and  similar  instruments,  if  they  involve  tendons, 
nerves,  and  vessels,  are  followed  by  ankylosis,  paralysis, 
and  atrophy.  Slight  lacerations  caused  by  nails  or  splint- 
ers, or  even  superficial  scratches,  may  lead  to  severe  cellu- 
litis (blood-poisoning).  Incised  woimds  caused  by  sharp- 
bladed  machines,  such  as  circular  saws  or  planing  ma- 
chines, are  always  grave  injuries,  causing  various  degrees 
of  mutilation  ;  one  or  more  fingers  or  parts  of  fingers  are 
23 


338  DISEA  SES  CA  USED  BV  A  CC I  DENTS. 


PLATE  2ft. 

Case  of  Mutilation  of  the  Fingers  by  a  Circular  Saw. 

A  sawyer,  forty  years  of  age,  on  December  28,  1hj)7,  had  his  index- 
finger,  middle  finger,  and  thumb  cut  through  the  bone  by  a  circular 
saw. 

The  colored  plate  shows  the  deformity  of  the  fingers  liotli  from  the 
flexor  and  extensor  surfaces.  The  accompanying  skiagra]>h  (Fig.  50) 
shows  the  changes  that  have  taken  i)lace  in  tlie  injured  joints  of  the 
index-finger  and  middle  finger.  The  thumV)  could  not  be  directly  ap- 
proximated to  the  plate  in  taking  the  skiagraph  without  causing  the 
impression  to  lose  in  clearness.  Insurance  allowance,  45%,  based  on 
the  inability  of  the  patient  to  close  the  affected  fingers. 


usually  cut  oflf',  or  the  wound  extends  so  deeply  into  the 
tissues  as  to  sever  muscles,  tendons,  vessels,  nerves,  and 
even  the  bone. 

The  joints  of  the  fingers  are  occasionally  sprained  by 
violently  pulling  at  an  object  or  by  the  effort  to  free  the 
fingers  when  they  are  caught  fast.  The  ca})sulcs  and  lat- 
eral ligaments  of  the  joints,  especially  of  the  metacarpo- 
phalangeal joints,  are  strained  and  slightly  torn,  leaving 
the  joint  weakened,  so  that  for  some  time  afterward  the 
patient  finds  himself  unable  to  grasj)  and  hold  an  object 
with  his  accustomed  strength. 

Similar  symptoms,  but  often  intensified,  are  observed 
after  dislocation  of  the  joints  of  the  fingers.  The  symp- 
toms of  dislocation  of  the  metacarpophalangeal  joints 
have  already  been  discussed.  When  the  other  two  joints 
of  the  finger  are  involved,  the  patients  comjilain  for  some 
time  after  reduction  is  practised  of  pain  and  a  I'eeling  of 
weakness,  especially  when  they  close  the  hand  or  hold 
something  in  it.  Sometimes  dislocation  is  accompanied  by 
fracture  of  the  phalanges. 

Ankylosis  of  the  affected  joint  is  more  frequently  a 
sequel  of  a  subluxation  than  of  a  complete  dislocation, 
since  the  former  is  apt  to  be  treated  as  a  sprain  and  left 
unreduced. 

Treatment, — Mechanical  treatment  usually  proves  sue- 


Tab.l^S 


Lith.  Anst  F-  ReichhoUI.  Miinrhen. 


Fig.  50. 


Fig.  51. 


340  DISEASES   CAUSED  BV  ACCIDENTS. 


PLATE  29. 

Fig.  1. — Case  of  Loss  of  the  Little  Finger,  together  with 
the  Head  of  the  Fifth  Metacarpal  Bone, 

A  \v()i'kinaii.  fi>ity-one  years  of  age,  sustained  a  comminuted  fracture 
of  the  nietacarp(>i)halanj;eal  joint  of  the  little  finfrer  of  the  left  hand, 
caused  by  the  lin,t;er  l)('inj2,  struek  ))y  a  beam.  The  little  finger  and 
the  head  of  the  fifth  metacarpal  bone  were  amputated. 

The  colored  plate  shows  the  scar  left  by  the  operation  and  the 
extent  to  which  the  hand  can  l)e  closed.  The  fourth  finger  does  not 
quite  touch  the  palm  of  the  hand.  The  accompanying  illustration  in 
black  and  white  (Fig.  ol )  shows  the  hand  when  fully  extended.  The 
fourth  finger  is  held  slightly  al)ducted  from  the  median  line  by  the 
tension  of  the  scar,  causing  the  slcin  over  the  extensor  tendon  of  the 
middle  finger  to  appear  like  a  distinct  fold. 

Fiu.  2. — Adherent  Scar  Over  the  Metacarpophalangeal 
Joint  of  the  Index=finger,  Due  to  an  Incised  Wound  Partly 
Severing  the  Bone  of  the  Joint. 

A  machinist,  thirty-two  years  of  age,  was  cut  in  the  left  hand  by  a 
circular  saw  on  January  29,  1892,  the  wound  opening  the  Joint.  The 
plate  shows  a  star-shaped  scar  adherent  to  the  bone  and  a  partial  for- 
ward dislocation  of  the  finger.  The  power  of  flexion  and  extension  of 
the  finger  has  never  been  completely  regained,  and  the  strength  of  the 
hand  is  slightly  diminished. 

Insurance  allowance,  15  fc . 

cessful.     The  patient  is,  as  a  rule,  only  slightly  incapaci- 
tated for  self-support. 

Fractures  of  the  Fingers. 

These  are  usually  direct  fractures,  and  may  be  caused 
by  blows  from  falling  objects,  blows  from  a  hammer,  or 
by  falling  and  striking  on  the  finger.  Indirect  fractures 
of  the  distal  phalanges  are  said  to  liave  occurred  as  a  result 
of  the  tension  of  the  extensor  tendons  when  the  fingers 
were  forcibly  flexed.  The  majority  of  ])halangeal  frac- 
tures occur  in  consequence  of  severe  crushing  of  the  hand. 

The  following  symptoms  are  manifested  after  union  is 
established  : 

The  finger  is  usually  thickened  at  the  point  of  fracture  ; 
sometimes  it  appears  broadened  and  shortened,  and  not 
infrequently  it  appears  convex  or  concave  on  its  flexor  or 
extensor  aspect.     If  the  fracture  involves  a  joint,  the  fin- 


7ab.l'/l 


Fig.l. 


Fig.  3. 


I.ith.Anst  /.'  Heichluild.  A/a/irheri . 


r 


FRACTURED  OF  THE  FINGERS. 


841 


ger  becomes  stiff  nnd  fixed  in  a  position  of"  flexion  or 
extension. 

The  position  of  the  adjacent  fingers  is  not  infrequently 
affected,  and  their  mobility  may  be  restricted. 

Treatment. — Passive  movements  should  be  begun  early, 
especially  when  the  fracture  involves  a  joint ;  the  fingers 
should  be  exercised  frequently,  even  while  the  bandage  is 
maintained,  the  latter  being  adjusted  with  this  in  view. 

Crusliing  of  the  distal  ])halanges  is  frequently  followed 
by  suppurative  inflannnation  of  the  nail-bed.  If  not 
removed  by  the  physician,  the  nail  is  usually  thrown  off' 
of  itself,  and  the  new  nail  that  grows  in  is  poorly  developed 


Fig.  52. 

and  misshapen,  merging  in  the  surrounding  skin.  The 
distal  phalanx  is  held  slightly  flexed,  and  can  neither  be 
completely  flexed  nor  extended.  It  may  be  very  painful, 
especially  if  a  neuroma  develops. 

No  after-treatment  is  required,  as  a  rule,  unless  the 
affected  phalanx  is  exceedingly  stiff  and  painful,  in  which 
case  local  baths  and  massage  usually  effect  a  recovery. 

The  presence  of  one  stiff  finger  is  a  source  of  great  in- 
convenience to  a  working-man,  making  it  difficult  to  take 
hold  of  an  object,  \vhile  the  finger  itself  is  constantly  hit- 
ting against  something  and  being  freshly  injured.  ^lore- 
over,  it  interferes  with  free  movement  on  the  })art  of  the 
adjacent  fingers.     This  is  most  noticeable  when  the  third 


342  DISEASES  CAUSED  BY  ACCIDENTS 


PLATE  :?o. 

Fig.  1. — Case  in  Which  the  Middle  Finger  Became  Shortened 
and  Stiffened  as  a  Result  of  Gangrene  from  the  Use  of  Car= 
bolic  Acid. 

A  workman,  thii-ty-nine  years  of  age,  lacerated  his  right  middle 
finger  on  a  nail  on  December  2,  1898.  He  paid  but  slight  attention 
to  tlie  wound,  simply  sncking  it  out  and  binding  a  rag  around  it. 
He  continued  to  work  until  the  third  day  after  the  jxccident,  when  his 
linger  became  swollen,  intiamed,  and  very  painful.  It  was  opened  by 
a  physician,  who  then  A\ashed  out  the  w ound  \\ith  w hat  purported  to 
])e  a  5'/f  solution  of  car1)olic  acid.  Tlie  tip  of  the  linger  is  said  to 
have  turned  black  at  once.  The  i)atient  ^\ould  not  permit  the  am- 
putation of  the  gangrenous  portion,  which  was  tlu'own  off  by  natural 
processes  in  the  course  of  al)Out  two  montlis.  Mechanical  treatment 
was  then  begun,  the  patient  being  unable  to  close  his  hand.  The 
middle  linger  was  perfectly  stiff,  the  fourth  linger  and  index-finger 
could  be  closed  one-third,  the  fifth  finger  somewhat  furtlier.  The 
patient  was  not  able  to  take  hold  of  anything  witli  his  hand.  Treat- 
ment was  continued  up  to  October  24,  18!)8,  when  he  was  discharged 
with  an  insurance  allowance  of  40%.  The  functional  power  of  the 
hand  was  sufficiently  restored  to  enable  him  to  take  hold  of  large 
ol)jects. 

Fig.  2. — Case  of  Paralysis  of  the  Ulnar  Nerve  due  toCrush= 
ing  of  the  Left  Shoulder. 

The  illustration  show s  a  \\ell-niarked  atrophy  of  the  interossei  and 
the  position  of  flexion  in  which  the  fingers  are  held.  The  paralysis 
appeared  about  two  weeks  after  the  injury,  the  hand  at  the  same  time 
becoming  greatly  swollen. 

Mechanical  treatment  has  brought  about  gradual  improvement;  the 
patient  has  not  yet  been  discharged. 

or  fourth  fini[>;er  is  involved,  especially  in  ease  of  the  third. 
It  is,  as  a  rule,  much  more  disadvantageous  to  a  working- 
man  to  have  a  stiif  middle  finger  than  to  lose  it  outright. 

Case  of  jmudo-fuihrosis  of  the  left  thninlt  due  to  an  ineised  wound  hy  a 
cutting  maehine. 

A  workman,  twenty-three  years  of  age,  A\as  cut  through  the  proxi- 
mal phalanx  of  the  left  thumb  by  a  cutting  machine  on  October  20, 
1890,  the  l)one  being  completely  severed.  A  false  joint  developed,  and 
the  thumlj  remained  entirely  useless  for  a  long  time.  The  illustration 
(Fig.  52)  sliows  the  deep  scar  around  the  thumb  and  the  ball  of  the 
thumb. 

The  patient  received  an  insurance  allowance  of  45%  up  to  March 
15,  1892,  based  on  his  inaliility  to  use  the  hand  and  the  atrophy  of  the 
whole  arm.  Impro\-ement  gradually  took  i)lace,  and  the  allowance  was 
reduced  to  25%,  at  which  rate  it  lias  remained.  The  thumb  is  still 
rather  weak. 


l\ih.  :U). 


fiy. 


fiij.l. 


FzgP 


l.i/h  Arisl  /■:  Reirhholcl.  Muiirhen 


Fig.  56. 


Fig.  55. 


344  DISEASES  CAUSED  BY  ACCIDENTS. 

Cusc  of  crushing  and  fracture  of  the  left  tliiimfi  canned  hji  an  iron  pipe 
falling  upon  it. 

The  lesion  was  treated  as  a  simple  case  of  cnishinj^  of  the  thunih. 

I  examined  the  i)atient  on  June  30,  189H,  and  found  the  thumb  still 
swollen  and  reddened,  presenting  a  suppuinting  wound  on  its  posterior 
surface.  The  wound  was  dressed  at  my  clinic  on  July  Hth,  but  the 
patient  did  not  again  return,  as  he  resumed  work  on  the  day  following. 
The  ac«)mpanying  skiagraph  (Fig.  5:5,  p.  :?43)  shows  the  condition  of 
the  thumb  at  that  time.     No  insurance  allowance. 

Case  of  .luhlu.rafion  and  tinkylosif^  of  the  distcd  phalangeal  joint  of  the 
right  thumb  caused  bi/  crushing  of  the  thumb  and  subse(pient  eellulitis. 

The  patient  was  a  workman,  thirty-three  years  of  age.  A  hod  filled 
with  lime  fell  on  his  right  thumb,  which  he  bandaged  with  a  piece  of 
paper  and  tied  with  a  string,  then  contiiuiing  his  day's  work.  On  the 
following  day  the  part  became  swollen,  the  swelling  finally  extending 
to  the  shoulder. 

When  discharged  from  treatment  he  was  conceded  an  insurance  al- 
lowance of  20%,  based  on  the  partial  ankylosis  of  the  thumb  and 
weakness  of  the  hand. 

The  skiagraph  (Fig.  54,  p.  343)  shows  the  subluxation  of  the  distal 
phalanx  of  the  thumli  and  the  changes  in  the  V)ones  of  the  joint. 

Case  of  bony  union  in  the  distal  phalangeal  Joints  of  both  thundjs  follow- 
ing fracture.  (Fig.  55,  p.  343.)  Sequel,  unimj)aired  usefulness  of  the 
thumbs. 

The  ])atient  had  injured  the  right  thumb  in  his  fourth  year  by  fall- 
ing and  directly  striking  upon  it;  the  left  tlnnub  was  injured  much 
later,  but  also  before  the  passage  of  the  Accident  Insurance  Law.  The 
functional  power  of  l)oth  thumbs  is  excellent,  notwithstanding  the 
fact  that  the  distal  phalanx  of  the  right  thumb  is  entirely  stiff. 

A  stiff  finger,  if  flexed,  is  more  favoral)le  to  the  use- 
fulness of  the  hand  than  if  extended,  partly  beeause  it 
may  aid  the  other  fingers  in  grasping  and  holding  articles, 
partly  because  it  is  much  less  in  the  way. 

Case  of  dislocation- fracture  of  the  hft  thund),  with  subsequent  ankylosis. 
(Fig.  56.) 

The  patient  was  a  workman,  thirty-nine  years  of  age.  On  July 
12,  1889,  a  plank  fell  upon  his  left  thuml),  producing  a  fracture  of  the 
proximal  phalanx.  The  upper  fragment  became  displaced  backward, 
and  union  took  place  in  this  position.  The  thumb  can  not  be  com- 
pletely flexed. 

Insurance  allowance  since  October  12,  1889,  10%  . 

Contractures  of  the  fingers  by  which  they  are  retained 
in  a  position  of  flexion  are  very  frequently  seen.  They 
may  be  caused  by  a  contracture  of  the  tendon  following 
a  tenosynovitis  (a  condition    quite  often   nut   with   as   a 


CONTRACTURES  OF  THE  FINGERS.  345 

professional  disease  in  certain  trades)  or  l)y  a  retracted 
scar.  Occasionally,  the  canse  is  a  mixed  one,  the  scar  left 
by  an  operation  having  become  adherent  to  the  flexor 
tendon. 

The  scars  left  on  the  stump  of  a  finger  after  amputation 
often  become  firndy  adherent  to  the  bone,  and  are  exceed- 
ingly sensitive  both  to  pressure  and  to  changes  of  tem- 
perature. They  are  also  apt  to  give  rise  to  a  painful  feel- 
ing of  tension  on  closing  the  hand. 

Occasionally,  such  a  stump  becomes  the  seat  of  a  neu- 
roma. This  is  more  likely  to  occur  if  the  stump  is  a 
broad  one,  as  when  it  includes  a  part  of  the  distal 
phalanx.  Neuromata  develop  more  frequently  in  the 
cases  in  which  the  finger  is  cut  off  by  a  machine,  such  as 
a  circular  saw  or  planing  machine,  and  esj)ecially  when  it 
is  crushed  off  Ijetween  cog-wheels,  than  after  an  amputa- 
tion by  the  surgeon.  The  presence  of  a  neuroma  impairs 
the  functional  power  of  the  part  to  a  much  greater  extent 
than  does  the  simple  loss  of  the  tip  of  the  finger.  The 
usefulness  of  the  stump  of  a  finger  depends,  of  course, 
on  its  length  ;  even  if  only  the  proximal  phalanx  is  left, 
it  is  of  assistance  in  maintaining  a  grip  on  an  object.  If 
painful  and  sensitive,  a  stump  is  rendered  comparatively 
useless. 

The  scars  that  follow  disarticulation  of  the  finger  at 
the  metacarpophalangeal  joint  become  retracted,  and  in 
case  of  removal  of  the  middle  or  fourth  finger,  cause  the 
tips  of  the  fingers  to  either  side  to  approach  each  other,  a 
change  of  position  often  associated  with  a  slight  rotation 
of  the  fingers.  Their  flexion  is  often  restricted  for  a  long 
time  afterward. 

The  position  of  the  adjacent  fingers  is  more  likely  to 
be  thus  affected  when  a  portion  of  the  metacarpal  bone  is 
also  removed  ;  the  scar  is  therel>y  made  larger,  while  the 
palm  of  the  hand  is  narrowed  or  drawn  together  in  the 
sha])e  of  a  boat.  Neuritis  is  sometimes  manifested  in 
severe  form  in  connection  with  these  scars. 


346  DISEASES  CAUSED  BY  ACCIDENTS. 

The  removal  of  tlie  fifth  finger  with  a  ])()rtiou  of  its 
metacarpal  bone  is  usually  followed  by  retraction  of  the 
scar,  causing  the  fourth  finger  to  become  abducted  from 
the  median  line  and  preventing  its  complete  flexion.  (See 
Plate  29,  Fig.  1.) 

Of  the  diseases  of  the  fingers,  we  need  here  consider 
only  the  paralyses  and  the  trophoneuroses  accompanied  by 
necrotic  ulcers.  The  former  occur  in  consequence  of 
direct  injury  of  the  nerves,  and  also  of  indirect  injury  : 
as,  for  instance,  the  paralysis  of  the  median  nerve  which 
is  quite  often  met  with  in  cases  of  fracture  of  the  radius. 
The  latter,  the  trophoneuroses  of  the  fingers,  are  observed 
when  the  ulnar  or  median  nerve  is  completely  severed. 

Case  of  compound  comminuted  fracture  of  the  proximal  phalanx  of  the 
left  index-finger. 

A  workman,  twenty-two  years  of  age,  sustained  the  foregoing 
injury  on  March  21,  1H9H,  caused  by  a  stone  from  a  wall  falling  on 
his  left  index-linger  from  a  height  of  two  stories. 

I  examined  him  on  Ajn'il  6,  li^O?^.  The  index-linger  was  swollen 
and  could  not  be  flexed.  Up  to  that  time  the  injury  had  been  treated 
as  a  simjjle  case  of  crushed  (contused)  wound  of  the  linger.  When 
discharged  from  my  treatment,  on  April  1(J,  ISfiH,  at  his  own  recjuest, 
the  finger  was  in  tlie  condition  shown  in  the  accomiianying  skiagraph. 
(See  Fig.  57. )     The  patient  was  fully  capable  of  self-support. 

Case  of  fixation  in  cvtension  of  the  right  indc.r-finger. 

The  patient  in  this  case  was  a  potter,  twenty -four  years  of  age. 
His  right  hand  was  caught  between  a  beam  and  an  overturned  barrel 
of  clay,  causing  a  contused  wound  of  the  right  index-finger,  ac«om- 
l)anied  by  a  partial  dislocation-fractmc  of  the  middle  jihalanx. 

When  I  examined  him,  on  September  2(1,  I  found  the  finger  moder- 
ately extended  and  fixed  in  that  ])osition.  It  was  stiff  and  much 
atrophied;  the  middle  ])halanx  was  encircled  by  a  deep  scar.  The 
skiagraph  shows  the  deformity  of  the  bone.  In  figure  58  the  finger 
lay  with  its  flexor  surface  against  the  plate,  while  in  figure  59  the 
side  of  the  finger  was  api)lied. 

The  patient  has  received  an  insurance  allowance  of  25%  since 
October  25,  1897,  based  on  the  fact  that  the  index-fhiger  is  stiff,  is 
constantly  in  the  way,  and  is  dejiressed  in  tem])eiature. 

(V(.s<'  of  fracture  of  the  distal  jihalanx  of  the  fourth  finger  of  the  right 
hand,  caused  hg  a  stone  fatting  u]>on  it. 

A  workman,  thirty-three  years  of  age,  sustained  the  foregoing 
injury.  He  was  treated  by  cold  compresses,  and  subsequently  by 
ointments. 

When  I  examined  him,  I  found  the  finger  swollen.  The  condition 
of  the  bone  is  shown  in  the  accompanying  skiagraph.     (Fig.  60,  p.  347. ) 


Fig.  60. 


Fig.  61. 


348  DISEASES  CAUSED  BY  ACCIDENTS. 

The  patient  was  unal)le  to  close  the  iiiiddh',  fourth,  and  little 
tinj^ers  coni]>letely.  He  continued  to  work  in  this  condition  with  the 
tinj^ers  l)au(la^cd,  and  did  not  return  for  treatment. 

('(ISC  of  cnisliiNf/  and  fr<u-1uir  of  the  dislal  phdlanges  of  the  middle  and 
fourth  Jjtif/irs  of  flic  rii/hf  liiiiid.      (  Fij;'.  61,  ]).  :>47.  ) 

The  i)atieut  was  a  liodn-arrier,  forty  years  of  age.  On  July  22,  1898, 
the  previously  designated  lingers  of  the  right  hand  were  crushed  be- 
tween two  iron  girders.  The  wound  was  dressed  by  his  own  physician, 
wlio  treated  him  for  a  crushed  linger  until  December  12,  1898.  At 
first  both  distal  phalanges  were  greatly  swollen,  thickened,  and  knob- 
like. When  discharged  l)y  his  physician,  tlie  swelling  had  disap- 
peared; nevertheless,  the  skiagraph  showed  a  sei)aration  of  the  frag- 
ments, as  here  rei>roduced. 

The  i)atient  was  considered  by  the  insurance  committee  of  his 
trade-union  to  be  able  to  work,  and  received  no  insurance  allowance. 

Case  of  (I  stiff  rii/lit  indcx-fiiiger  with  adherent  sears  on  the  flexor 
surface. 

A  workman,  fifty-two  years  of  age,  lacerated  the  I'ight  index-finger 
on  a  splinter  wiien  engaged  in  cutting  wood.  He  paid  no  attention 
to  the  wound  at  first.  A  few  days  later  the  finger  became  swollen,  the 
swelling  extending  to  the  hand  and  arm.  Cellulitis  was  diagnosed  and 
an  operation  was  performed.  The  flexor  tendon  was  subseciueutly 
removed. 

Insurance  allowance,  20%. 

Ca.se  of  loss  of  one-half  of  index-flnger,  of  almost  one-half  of  the  middle 
flnger,and  of  one-half  of  the  distal  phalanx  of  the  fourth  finger. 

The  patient  was  a  sawyer,  thirty-two  yeai's  of  age.  On  April  9, 
1897,  his  left  hand  was  caught  in  a  planing  machine  and  the  fingers 
cut  off,  as  previously  mentioned. 

After  the  wounds  had  healed,  the  patient  was  able  to  flex  the  fourth 
and  little  finger  perfectly  ;  the  stump  of  the  middle  finger  could  be 
flexed  at  the  metacarpoi)halangeal  joint  to  an  angle  of  11)0  degrees, 
while  the  stump  of  the  index-finger  could  not  be  flexed  at  all.  The 
strength  of  the  hand  A\as  diminished. 

On  October  21,  1897,  the  patient  was  conceded  an  insurance  allow- 
ance of  33J%,  which  was  later  raised  by  legal  process  to  40%.  It  was 
reduced  to  25%  on  April  15,  1898,  imj)rovement  in  respect  to  flexion 
and  strength  having  taken  i)lace.  The  patient  receives  full  pay  for  liis 
work. 

Case  of  dislocation  of  the  third,  fourth,  and  fifth  fingers  of  the  left  hand 
at  their  metaearpophalangcal  Joints.  The  lesion  \\as  caused  by  a  beam 
falling  on  the  fingers. 

The  ]iatient,  a  carpenter,  forty-five  years  of  age,  sustained  the  fore- 
going injury  on  February  3,  1892.  The  dislocation  was  reduced,  but 
the  metacarpophalangeal  joint  of  the  middle  fingei'  remained  abnor- 
jnaliy  movable.  The  whole  hand,  as  well  as  the  middle  finger,  was 
mucii  Aveakened.  Tlie  ])atient  was  nnal^le  to  exert  firm  pressure  with 
the  middle  or  fourth  finger  ;  symptoms  of  paresthesia  and  of  ascending 
neuritis  were  also  manifested.  Insurance  allowance,  40%  ;  the  patient 
died  subsequently  of  an  internal  disorder. 


CASES  OF  IXJURIES  TO  THE  FIXGERS. 


349 


Case  of  severe  erusfiinff  of  the  right  middle  finf/er.  Sequels  :  The 
affected  finger  became  much  shortened  and  ankylosed  in  a  position  of 
flexion  ;  the  whole  hand  could  be  only  j)artly  closed. 

A  workman,  sixty-three  years  of  age,  the  subject  of  this  case,  is 
unable  to  use  his  hand  for  work,  and  receives  an  insurance  allowance 
of  50^. 

Case  of  disarficulotion  of  the  right  middle  finger.  Prolonged  course 
of  surgical  treatment  and  severe  neuritis  lasting  for  a  long  time. 

A  workman,  twenty-four  years  of  age,  was  injured  on  December  6, 
1889,  by  a  stone  falling  on  the  right  middle  finger.  Sui)puration  set 
in,  and  the  finger  was  finally  disarticulated  on  August  11,  1891.  An 
attempt  had  been  made  to  preserve  the  finger  in  a  position  of  flexion, 
but  this  was  gi\en  up  because  the 
finger  became  closely  pressed  against 
the  palm  of  the  hand. 

The  patient  su))sequently  attended 
several  different  clinics,  finally  going  to 
a  clinic  for  nervous  diseases,  where  he 
was  treated  for  a  neuritis  of  the  median 
nerve  by  mass;ige  and  electricity. 

On  May  1~),  189:i,  he  was  conceded  an 
insurance  allowance  of  (JO  'v ,  which  by 
legal  process  was  raised  to  80%.  He 
was  under  treatment  for  three  and  a 
quarter  years. 

In  1895  it  was  disco\'ered  that  he  was 
again  at  A\ork,  and  ■v^•as  receiving  full 
I)ay.  His  insurance  allowance  was  ac- 
cordingly reduced  to  '35% .  He  had  not 
reco^'ered  the  ])ower  of  closing  his  hand 
until  about  the  year  1895. 

Case  of  disitrtieuhdion  of  the  middle 
finger  subsequent  to  erushinq  of  the  finger 
and  eetlulitis.      (Fig.  62.  )  "     " 

The  subject  of  the  accompanying 
illustration,  which  was  made  on  the  day 
of  his  discharge,  was  a  workman,  thirty- 
one  >'ears  of  age.     The  imperfect  closure 

and  the  convergence  of  the  fourth  and  fifth  fingers  are  distinctly 
shown.  The  accident  occurred  on  September  29,  1898,  and  the  finger 
was  disarticulated  on  I)eceml)er  5,  1898.  The  patient  wa^s  given  a 
course  of  after-treatment  lasting  from  January  6,  1899,  to  May  20, 
1899.     Insurance  allowance,  25^^. 

Cose  of  eontraeture  of  the  right  middle  finger  in  a  position  of  flexion, 
causing  severe  functional  disability  of  the  hand,  rendering  it  useless  for  a 
long  time. 

The  piitient  was  a  workman,  forty  years  of  age.  On  July  11,  1892, 
an  iron  gii'der  fell  upon  the  middle  finger  of  his  right  hand  ;  the  injury 
was  followed  by  a  suppurative  inflammation,  necessitating  deep  inci- 
sions in  the  finger. 


Fig.  62. 


.350  DISEASES  CAUSED  BY  ACCIDENTS. 

When  I  examined  the  patient,  on  October  6,  1892,  I  found  the  middle 
finger  slightly  flexed  and  qnite  stiff.  The  other  fingers,  with  the 
exception  of  the  thumb,  could  not  be  closed.  The  muscles  of  the  hand 
were  greatly  atrophied,  the  hand  felt  cold  and  numb  to  the  patient, 
while  the  scar  and  the  whole  palm  of  the  hand  were  exceedingly  sensi- 
tive. 

The  patient  remained  under  treatment  until  June  20,  1893  ;  he  was 
conceded  an  insurance  allowance  of  50%,  which  was  later  reduced  to 
40%;.  By  September  10,  1896,  the  condition  had  somewhat  improved  ; 
the  patient  could  close  his  fingers  somewhat  better,  and  the  hand, 
although  still  weak,  presented  a  more  normal  appearance.  The  insur- 
ance allowance  could  not  be  reduced. 

Ccuse  of  removal  of  the  fourth  finger. 

The  patient,  a  carpenter,  forty-fi\e  years  of  age,  sustained  a  com- 
pound comminuted  fracture  of  his  fourth  finger  on  October  25,  1889. 
The  injury  was  caused  by  his  finger  being  caught  in  the  guy-rope  of  a 
flagstaff.  The  finger  was  removed.  The  operation-scar  extended  to 
the  ijalm  of  the  hand  and  prevented  the  closure  of  the  index-finger 
and  the  middle  and  little  fingers.  The  hand  became  atrophied  and 
paresthetic  ;  the  scar  was  exceedingly  sensitive.  The  patient  was  dis- 
charged on  March  20,  1891,  with  an  insurance  allowance  of  40%,  after- 
ward raised  by  legal  process  to  55  %  . 

Case  of  complete  contracture  of  the  fourth  and  fifth  fingers  and  almost 
complete  contracture  of  the  indcx-fingcr  and  middle  finger  of  the  left  hand, 
following  an  accident  by  which  the  tendons  were  severed  at  the  wrist. 

A  roofer,  twenty -eight  years  of  age,  fell  from  a  roof  about  fifteen 
feet  high,  on  April  7,  1887,  striking  the  left  wrist  against  a  sharp- 
edged  slate  tile.  He  was  treated  in  the  hospital  for  a  number  of 
weeks,  and  afterward  received  electric  treatment  from  a  nerve  spe- 
cialist.    No  improvement  was  attained. 

Insurance  allowance,  60%  at  firet;  raised  by  legal  pi'ocess  to  80%, 
later  reduced  to  50%.  The  hand  can  be  used  with  difficulty  as  an 
atljunct  to  the  right  hand. 

Case  of  crushing  of  the  distal  phalanges  of  the  index-finger  and  of  the 
middle  and  fourth  fingers.  Sequels,  rudimentaiy  formation  of  the 
nails  and  inability  to  flex  com])letely  the  affected  fingers  at  the  distal 
phalangeal  joints. 

A  carpenter,  thirty-four  years  of  age,  sustained  the  foregoing  in- 
jury, which  wa»s  caused  by  his  hand  being  caught  lietween  a  rope  and 
a  cleat.  After  the  wounds  had  healed,  the  fingers  coidd  at  first  be 
neither  completely  flexed  nor  extended.  The  patient  was  allowed  20% 
insurance  on  account  of  the  impairment  of  functional  power  and  of 
a  slight  flexion  contracture  of  the  fingers. 

Case  of  severe  contracture  of  the  right  middle  finger,  the  tip  of  the  finger 
being  in  contact  with  the  jxdm  of  the  hand. 

The  patient  was  a  man  thirty-flve  years  of  age,  of  delicate  health. 
The  contracture  of  the  finger  dated  from  a  previous  injury,  but  wjis 
increased  by  a  sui)purative  inflannnation,  whicii  originated  in  a  slight 
laceration  of  the  finger.     The  insurance  allowance  was  only  10%. 

The  patient  is  able  to  hold  articles  that  are  placed  in  his  hand. 


INSURANCE  AND  HAND  INJURIES.  351 

Case  of  removnl  of  the  dhfal  jyhnhnif/es  of  the  index-finger  and  of  the 
middle  and  fourth  fingers  of  the  left  hand. 

The  patient  was  a  workman,  fifty-fonr  years  of  age.  On  Sep- 
tember 29,  1892,  his  left  hand  was  caught  between  the  rope  and  the 
drum  of  an  elevator,  crushing  tlie  previously  mentioned  fingei-s,  and 
necessitating  amputation  of  the  distal  phalanges.  The  hand  became 
entirely  iiseless.  Insurance  allowance,  r>0'/r.  On  NovemV>er  10, 
1893,  the  patient  sustained  a  fracture  of  the  third  metacarpal  bone  of 
the  right  hand,  for  which  injury  an  insurance  allowance  of  10^  was 
conceded,  giving  a  total  allowance  of  60%. 

Estimation  of  Indemnity  for  the  Sequels  of  Injuries  of  the 
Hand  and  Fingers. 

The  following  scale  of  indemnity  rates  was  at  one  time  employed 
in  a  number  of  trades-unions  : 

Loss  of  thumb right,  '25%  ;  left,  20% 

"         index-finger.    ...       "      18%;      "    14% 

"        middle  finger    ...       "      13%;      "10% 

fouilh  finger     ..."        9%;      "      7% 

"         little  finger  ....       "      12%;      "      9% 

The  loss  of  a  phalanx  of  the  thumb  was  considered  to  equal  one- 
half  the  loss  of  the  entire  thumb;  in  case  of  the  other  fingers,  the  loss 
of  one  phalanx  equaled  one-third  the  loss  of  the  entire  finger. 

This  table  has  been  changed  in  various  ways.  It  was  found  to  be 
more  practicable  to  make  use  of  round  figures,  such  as  20%  or  15%, 
instead  18%  or  14%.  Further  changes  were  induced  by  a  recogni- 
tion of  the  justice  of  placing  a  higher  estimate,  in  many  cases,  on  the 
loss  of  the  middle  finger  than  on  the  loss  of  the  index-finger. 

I  have  personally  come  to  allow  30%  for  the  loss  of  the  entire 
right  thumb;  20%  for  the  right  middle  finger  and  15%  for  one  of 
the  other  fingers.  In  case  of  the  left  hand,  I  allow  25%  for  the 
thumb,  15%  for  the  middle  finger,  and  10%  for  one  of  the  other 
fingers. 

In  a  paper  read  at  the  meeting  of  German  naturalists  and  physi- 
cians held  at  Brunswick  in  1897,  J.  Riedinger  proposed  a  different 
basis  for  the  estimation  of  indemnity  for  the  fingers,  for  which  he 
adduced  physiologic  and  practical  rea.sons.  He  states  that  as  the 
usefulness  of  the  human  hand  deijends  less  upon  its  strength  than 
on  the  harmonious  action  of  all  the  fingers,  it  is  unreasonable  to  dif- 
ferentiate between  them  in  resjiect  to  indemnity,  except  in  the  case  of 
the  thumb.  The  middle  finger  is  the  strongest,  as  becomes  very  evi- 
dent when  it  is  lo.st.  The  index-finger,  however,  dii'ects  the  action  of 
the  other  fingers,  and  displays  the  be,st-<leveloped  tactile  sense  of  all. 
Its  relative  value,  therefore,  is  equal  to  that  of  the  middle  finger.  Tlie 
little  finger  forms  the  lateral  termination  of  the  row  of  fingers,  just 
as  the  ball  of  the  little  finger  forms  the  ))Oundary  of  the  hand.  If 
the  little  finger  is  removed,  the  mu.scles  of  the  ball  of  the  little 
finger  undergo  considerable  atrophy.     In  order  to  exert  any  strength, 


352  DISEASES  CAUSED  BY  ACCIDENTS. 

however,  the  little  finger  is  obliged  to  act  in  unison  witli  the  fourth 
finger.  Because  of  the  close  relation  and  interdependence  of  the 
fingers,  the  loss  of  any  one  of  tlie  other  fingers  sliould  in  some  respects 
be  rated  higher  than  the  loss  of  the  index-finger. 

Each  finger,  therefore,  has  its  own  specific  value,  and  its  loss  is  felt 
by  the  whole  hand.  The  unfavorable  effect  of  the  loss  of  a  finger  is 
greater  the  more  of  tlie  metacarpal  bone  is  rem()\ed. 

Kiedinger  also  disputes  the  justice  of  rating  the  right  hand  higher 
than  the  left,  claiming  that  the  special  work  performed  by  the  latter 
deserves  ecjual  consideration.  He  admits,  however,  the  impossibility 
of  overcoming  the  deep-rooted  prejudice  in  favor  of  the  right  hand  all 
at  once,  and  takes  this  into  consideration  in  preparing  the  following 
table,  which  1  cite  here  for  tlie  reason  that  it  has  certain  distinct  ad- 
vantages over  the  others  in  use,  especially  in  regard  to  the  rates  for  the 
loss  or  partial  loss  of  several  fingers. 

When  the  Hand  Proper  Is  Intact. 

40  (30)% 


Thuml).  Index-finger.     Middle  Finger.  Fourth  Finger.   Little  Finger. 

25(20)%    15(10)%  15(10)%  15(10)%  15(10)% 


40(30)%  25(20)%  25(20)% 


50(40)%  40(30)% 


50  (40): 


75  (60)% 

When  the  Hand  Proper  Is  Affected. 
55  (45)% 


Thumb.  Index-finger.     Middle  Finger.  Fourth  Finger.   Little  Finger. 

35(30)%     25(20)%  25(20)%  25(20)%  25(20)% 

55  ( 45 )  %  35  ( 30 )  %  35  ( 30 )  % 

65(50)%  55(45)% 

65  (50)% 
75(60)% 


INJURIES  OF  THE  LOWER  EXTREMITY.  353 

I  also  fully  agree  with.  Kiedinger  in  his  a.ssertion  that  the  disarticu- 
lation of  a  finger  impairs  the  usefnlness  of  the  hand  to  a  much  greater 
degree  than  an  anipntation  of  the  proximal  phalanx. 

In  estimating  the  allowance  for  stiffness  of  a  finger,  the  loss  of  the 
functional  power  of  the  adjacent  lingers  must  be  taken  into  considera- 
tion. If  only  the  metacarjiophalangeal  joint  is  stiff,  and  the  other 
fingers  are  not  affected,  the  injury  sliould  be  rated  at  two-thirds  of  the 
entire  finger.  If  the  midjjhalangeal  joint,  however,  is  stiff,  the  rate 
should  equal  that  for  the  loss  of  the  entire  finger. 

The  rate  for  a  completely  ankylosed  or  paralyzed  finger  should  be 
higher  than  for  the  complete  loss  of  a  finger,  since  it  is  constantly  in 
danger  of  being  hit  and  injured. 

Stiffness  of  a  distal  phalanx  does  not  limit  the  usefulneas  of  the 
hand. 

The  thumb,  even  if  completely  stiff,  may  be  quite  useful,  as  it 
retains  its  power  of  opposition. 

The  contracture  of  a  finger,  if  it  has  progressed  so  far  as  to  bring  the 
end  of  the  finger  into  contact  with  the  palm  of  the  hand,  disables  the 
whole  hand  for  working  purposes.  If  tlie  contracture  is  less  far 
advanced,  and  the  hand  can  be  used  for  taking  hold  of  objects,  there 
may  be  no  loss  of  working  capacity. 

The  most  unfavorable  re-sults  of  contractiire  are  ^en  when  the 
metacarpophalangeal  joint  is  involved ;  contracture  of  the  mid  phalan- 
geal joint  ranks  second  in  this  respect.  A  contracture  of  the  distal 
phalangeal  joint  does  not  restrict  the  working  power  of  the  patient. 

For  the  rating  of  tlie  loss  of  part  of  a  finger  I  refer  the  reader  to  the 
table.  If  only  one-third  of  the  finger  is  lost,  its  usefulness  is  only 
slightly  impaired ;  if  more  than  two-thirds  are  lost,  the  rate  equals  that 
for  the  loss  of  the  entire  finger. 

The  rates  as  here  cited  may  call  for  considerable  modification  if 
functional  power  is  further  impaired  by  such  complications  as  painful 
scars,  cicatricial  adhesions,  callosities,  neuromata,  etc. 


VI.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
LOWER  EXTREMITY. 

Remarks  Cnnccrnin;/  the  Anatomy  and  Function  of  the  Pelris  and  Hip- 
joint. — In  distinction  to  tlie  uj^per  extremities,  which,  by  the  arrange- 
ment of  their  various  joints,  are  .so  admirabl}-  equipi)ed  for  grasping 
and  holding,  the  lower  extremities  have  the  function  of  supporting 
and  moving  the  Itody. 

The  two  innominate  bones  are  separated  posteriorly  l)y  the  sacrum, 
which  is,  as  it  were,  swiing  between  them  on  the  posterior  sacro-iliac 
ligaments.  The  weight  of  the  body,  supported  by  the  spinal  column, 
is  transmitted  througli  the  sacrum  and  the  hip-joints  to  the  lower  ex- 
tremities. The  pressure  on  the  .sacrum  from  ahove  causes  the  posterior 
ligaments  of  the  pelvis  to  become  tense,  drawing  the  posterior  portions 
23 


354  DISEASES  CAUSED  BY  ACCIDENTS. 

of  the  ilia  toward  the  median  line,  thereby  increasing  the  pressure 
exerted  on  the  sacrum  by  the  innominate  bones  on  eacli  side.  The 
greater  the  weight  to  be  supported,  the  more  tightly  is  the  sacrum 
wedged  in  between  the  innominate  bones. 

The  hip-joint,  which  is  formed  by  the  acetabulum  on  one  side  and 
the  head  of  the  femur  on  the  other,  is  a  limited  ball-and-socket  joint. 
The  cavity  of  the  acetabulum  is  deepened  }\y  the  cotyloid  ligament, 
which  acts  as  a  vahe,  preventing  the  entrance  of  air  into  the  joint. 
Even  when  all  the  soft  parts  connected  with  the  joint,  including  the 
capsule,  are  removed,  the  head  of  the  femur  will  not  slip  out  of  the 
acetabulum  as  long  as  the  cotyloid  ligament  remains  intact. 

The  capsular  ligament  is  thin  in  certain  places  ;  it  is  strong  ante- 
riorly, where  it  is  reinforced  by  the  iliofemoral  ligament.  This  liga- 
ment is  so  strong  that  overtension  on  its  part  is  Ciipable  of  causing  a 
fracture  of  the  neck  of  the  femur,  and  it  occasionally  forms  an  insup- 
erable ol)stacle  to  the  reduction  of  a  dislocation  of  the  hip-joint.  It 
serves  to  limit  the  extension  of  the  hip-joint,  or  the  l)ending  of  the 
trunk  backward  ;  its  chief  function,  however,  will  l)e  referred  to  further 
on.  Internally,  the  capsular  ligament  is  supported  by  the  pul)ofem- 
oral  ligament,  tension  of  which  prevents  overaV)duction  of  the  thigh. 
Abduction  is  also  limited  by  contact  between  the  great  trochanter,  or 
the  neck  of  thfe  femur,  and  the  side  of  the  pelvis.  It  is  between  the 
iliofemoral  and  pubofemoral  ligaments  that  the  weakest  portion  of  the 
capsular  ligament  is  to  be  found.  Overadduction  of  the  thigh  is  pre- 
vented by  the  tiension  of  the  iliofemoral  ligament,  and  also  by  the  liga- 
mentum  teres  in  cases  in  which  the  latter  is  very  sliort.  It  is  geher- 
ally  admitted  that  the  ligamentirm  teres  is  not  capable  of  retaining  the 
head  of  the  femur  in  position  ;  it  is  regularly  torn  through  in  eases  of 
dislocation  of  the  joint,  unless  it  is  abnormally  long  ( from  8  to  10  cm.). 
In  the  latter  case  it  may  interfere  with  reduction  by  becoming  caught 
between  the  bones.  Unusual  length  of  the  ligament  may  also  act  as  a 
cause  of  congenitiil  dislocation  of  the  hip-joint.  It  transmits  the  acet- 
abular artery,  which  is  very  important  in  connection  witli  the  syno- 
vial secretion  of  the  joint.  The  artery  is  said  to  terminate  before 
reaching  the  head  of  the  femxir. 

A  mass  of  fat  surrounded  by  s^movial  membrane  lies  on  the  floor 
of  the  acetabulum,  where  the  ligamentum  teres  is  inserted  ;  it  serves 
to  protect  the  acetabulum  at  this,  its  weakest  point.  When  an  ab- 
scess of  the  hip-joint  breaks  into  the  pelvis,  or  when  an  abscess  passes 
out  of  the  pelvis  into  the  hip-joint  or  on  into  the  iliaf;  bursa,  it  is  at 
this  point  that  perforation  usually  takes  place. 

The  filjrous  layer  of  the  joint-capsule  is  inserted  l)elow,  along  the 
spiral  line  of  the  femur,  the  sjniovial  lining  being  inserted  one  centi- 
meter higher  on  the  bone.  Posteriorly,  lioth  fi})rous  and  synovial 
sheaths  are  inserted  on  a  line  running  across  the  neck  of  the  femvrr 
about  half-way  down.  The  psoas  and  iliac  muscles  are  separated  from 
the  capsular  ligament  by  a  bursa, — the  iliac  or  subiliac  bursji, — 
which,  as  a  rule,  does  not  communicate  with  the  capsule  of  the  joint, 
although  cases  in  which  such  a  communication  does  exist  are  often 
met  with,   especially  in  old  age.     As  alreatly  stated,   abscesses  may 


ANATOMY  OF  THE  HIP.  355 

pass  from  tliis  bui-sa  into  the  liii)-joint,  and  so  into  the  pelvic  cavity, 
or  vice  versa. 

The  hijj-joint  permits  of  the  follo\\inf:^  movements  : 

1.  Flexion. — The  thijih  can  be  flexed  on  the  trunk,  when  the  knee 
is  bent,  to  an  angle  of  about  115  degrees  (angle  betAveen  trunk  and 
thigh.  (55  degrees ) ;  when  the  knee  is  extended,  to  an  angle  of  about  75 
degrees  (angle  lietween  trunk  and  thigh,  105  degrees).  This  move- 
ment is  produced  by  the  iliopsoas  muscle  (supplied  by  the  anterior 
crural  and  anterior  branches  of  the  lumV)ar  nerves). 

Extreme  flexion  is  accompanied  by  a  certain  degree  of  outward 
rotation.     During  flexion  the  iliofemoral  ligament  is  relaxed. 

2.  Extcmion. ^The  thigh  can  lie  extended  to  an  angle  of  about  30 
degrees  (angle  between  trunk  and  thigh,  150  degrees).  The  muscle 
here  concerned  is  the  gluteus  maximus,  supplied  by  the  inferior 
gluteal  nerve.  During  extension  the  iliofemoral  ligament  is  put  on 
the  stretch. 

3.  Abduction. — This  movement  can  be  carried  to  an  angle  of  about 
from  30  to  40  degrees  (angle  between  trunk  and  thigh,  from  150  to 
1 40  degrees.  The  muscles  in  action  are  the  gluteus  medius  and  gluteus 
minimus,  supplied  by  the  superior  gluteal  nerve.  Extreme  abduction 
is  accompanied  by  a  cei-tain  degree  of  inward  rotation. 

4.  Adduction. — This  movement  can  be  carried  to  an  angle  of  about 
30  degrees  (thigh  and  trunk  form  a  supplementary  angle  of  150  de- 
grees when  one  leg  thus  crosses  the  other ) .  The  muscles  concerned  are 
the  several  adductors,  the  pectineus,  and  the  gracilis,  supplied  by  the 
ol)turator  nerve. 

5.  Rotation  : 

(a)  Outuard  Rotation. — This  is  prodiiced  by  the  pjTiformis,  the 
obtiu-ator  internus,  the  gemelli,  and  the  quadratus  femoris  (supplied 
by  branches  from  the  s<icral  plexus),  and  by  the  obturator  externus 
( supplied  by  the  obturator  nerve ) . 

{b)  Inward  Rotation. — This  is  produced  by  the  anterior  fibers  of  the 
gluteus  medius. 

Statistics. — The  2403  cases  of  recovery  from  injuries  of  the  lower 
extremity  supplying  the  material  for  the  following  sections  involved 
the  different  regions  as  follows  : 

Pelvis,  including  hip-joint 169  cases. 

Thigh      248  " 

Knee,  including  patella 339  ' ' 

Leg 346  " 

Ankle-joint,  including  malleoli     ....  711  " 

Bones  of  the  carpus 304  ' ' 

Foot  proper,  or  sole  and  back  of  the  foot  169  " 

Toes 117  " 

2403  cases. 


356  DISEASES  CAUSED  BY  ACCIDENTS. 


I.  INJURIES  OF  THE  PELVIS. 

(Sixty-eight  Cases. ) 

Contusions  of  the  Buttocks. 

The  buttocks,  by  reason  of  their  protected  position,  are 
insured  against  serious  effects  from  contusions,  unless  the 
injury  is  a  severe  one,  such  as  a  fall  in  a  sitting  posture. 

Such  an  accident  may  cause  : 

1 .  A  more  or  less  extensive  hemorrhagic  extravasation, 
which,  as  a  rule,  soon  becomes  absorbed. 

2.  A  severe  contusion  of  the  sciatic  nerve,  followed  by 
neuritis.  Traumatic  sciatica  may  also  occur  as  a  result 
of  falling  when  in  a  squatting  position,  so  as  to  bring  the 
buttocks  into  contact  with  the  heel  of  the  boot.  Lumbago 
may  be  associated  witli  the  sciatica. 

The  symptoms  of  traumatic  sciatica  are  precisely  sim- 
ilar to  those  of  the  nontraumatic  form,  except  that  in  the 
early  stages  the  former  is  usually  accompanied  by  signs 
of  external  injury.  Recovery  may  be  extremely  slow  ; 
particularly  obstinate  cases  are  marked  by  the  develop- 
ment of  a  scoliosis. 

Recovery  is  best  promoted  by  warm  baths,  massage, 
applications  of  ether,  medicomechanical  exercises,  and  weak 
galvanism.  Some  patients  respond  more  quickly  and  sat- 
isfactorily to  a  strong  faradic  current.  Others  are  unable 
to  endure  massage  at  all.  The  idiosyncrasy  of  the  patient 
must  therefore  be  taken  into  consideration  in  the  treat- 
ment. 

When  the  sciatic  nerve  is  severed  by  a  foil  against  the 
blade  of  a  hatchet  or  other  sharp-bladed  instrument,  the 
injury  can  be  successfully  repaired  by  nerve-suture,  in 
which  ]irocedure  lies  the  only  ])ossible  hope  of  preventing 
severe  })aralysis. 

The  paticut  is  entirely  incapacitated  for  self-support  as 
long  as  he  suffers  from  pain  in  the  limb  and  from  inalnlity 
to  walk   well  or  to  walk  at  all.     Other  cases  must  be 


FRACTURES  OF  THE  PELVIS.  357 

judged  according  to  the  severity  of  the  pain  and  its  eflfect 
on  the  patient,  whose  working  ca})acity,  if  the  pain  is 
slight,  is  not  necessarily  impaired  at  all. 

The  anatomic  relation  of  the  parts  explains  the  frequent 
involvement  of  the  hip  in  cases  of  contusion  of  the 
buttocks. 

Case  of  contusion  of  the  bttttocks  leading  to  chronic  synovitis  of  the  hip- 
joint. 

A  painter's  apprentice,  seventeen  years  of  age,  fell  from  a  roof  nine 
feet  high  on  Jannary  16,  1896,  striking  on  the  buttocks.  He  was 
treated  at  home  for  nine  weeks  by  rest  in  bed  and  inunctions,  and  was 
then  taken  to  the  hospital  for  six  weeks,  during  which  time  an  exten- 
sion apparatus  was  applied.  Eighteen  weeks  after  the  injury  he  began 
to  do  light  work. 

I  examined  him  on  September  6,  1899.  He  was  undersized;  the 
right  side  of  the  pelvis  was  depressed  below  the  level  of  the  left  side. 
The  distance  from  the  umbilicus  to  the  anterior  spine  of  the  ilium 
measured  15  cm.  on  the  right  side  and  11]  cm.  on  the  left  side,  when- 
the  patient  was  standing;  the  distance  from  the  iliac  spine  to  the 
ground  was  8;^  cm.  on  the  right  side  and  90  cm.  on  the  left  side.  Tlie 
distance  from  the  trochanter  to  the  ground  was  SZh  cm.  on  both  sides. 
The  mobility  of  the  right  hip-joint  was  restricted,  and  the  knee  was 
held  slightly  flexed.  The  patient  limped  when  he  walked.  The  mus- 
cles were  atrophied  on  the  right  side,  the  circumference  of  the  limb 
being  SJ  cm.  less  than  that  of  the  left  side. 

The  skiagraph  showed  no  changes  in  the  bones. 

Diagnosis. — Chronic  synovitis  of  the  right  hip-joint. 

Insurance  allowance,  33J  % . 


Fractures  of  the  Pelvis. 

( Forty-seven  Cases. ) 

As  a  rule,  this  lesion  is  met  with  only  in  cases  of  severe 
accident,  such  as  falling  from  a  height  on  the  buttocks,  or 
being  run  over,  caught  under  a  falling  building,  or  crushed, 
when  lying  prone,  by  the  fall  of  a  heavy  object,  such  as  a 
beam,  block  of  stone,  etc.  When  the  fracture  is  caused 
by  being  riui  over  or  crushed  under  falling  walls,  we  are 
likely  to  lind  a  fracture  or  dislocation  of  the  sacrum  as 
well.  A  fracture  of  the  pelvis,  if  complicated  by  lesions 
of  the  urethra  or  of  any  of  the  pelvic  organs,  is  always  to 
be  regarded  as  a  grave  accident. 


358  DISEASES  CAUSED  BY  ACCIDENTS. 

The  following  symptoms  are  observ^etl  in  the  later 
stages  of  the  injury  : 

lu  cases  of  fracture  of  the  ilium  the  anterior  superior 
spine  lies,  as  a  rule,  on  a  lower  level  than  that  of  the 
opposite  side.  The  affected  side  of  the  pelvis  is  usually 
narrowed  l)y  a  transverse  frac^ture  of  the  iliuni,  caused  by 
direct  violence  on  the  side,  and  the  distance  between  the 
umbilicus  and  the  anterior  superior  spine  is  decreased. 
The  lower  extremity  is  apparently,  but  not  actually,  short- 
ened by  a  fracture  of  the  iliuni.  This  fact  can  easily  be 
determined  by  measuring  the  patient  when  standing  and 
when  lying  down.  When  standing,  the  distance  from  the 
anterior  superior  spine  to  the  ground  is  shortened  ;  if, 
however,  we  measure  from  the  apex  of  the  great  trochan- 
ter to  the  spine  or  crest  of  the  ilium,  and  then  from  the 
trochanter  to  the  apex  of  the  external  malleolus,  we  find 
that  no  real  shortening  exists.  The  line  between  the  an- 
terior superior  spine  and  the  trochanter  is  shorter  on  tlie 
affected  side  ;  the  trunk  is  somewhat  inclined  toward  that 
side,  and  the  spinal  column  presents  a  corresponding  degree 
of  scoliosis.  Frequently,  the  leg  of  the  injured  side  is 
rotated  outward  ;  occasionally,  it  is  rotated  inward,  while 
the  uninjured  knee  is  somewhat  flexed.  The  muscles  of 
the  lunil)ar  region  and  of  the  buttocks,  also  the  iliopsoas, 
tensor  vaginse  femoris,  rectus,  and  sartorius,  undergo  more 
or  less  atrophy,  and  the  affected  thigh  can  not  be  flexed 
so  vigorously  as  the  normal  one.  The  pelvis  is  sensitive 
to  pressure,  both  anteriorly  and  posterioi'ly,  on  the  injured 
side,  and  the  relation  between  the  sacrum  and  iliuni  on  that 
side  is  more  or  less  changed  from  the  normal. 

The  depression  of  the  pelvis  and  the  other  signs  of  dis- 
placement are  likely  to  be  more  marked  in  projiortion  to 
the  extent  of  the  fracture,  or  to  the  degree  of  violence 
that  caused  it ;  this  is,  however,  not  at  all  necessarily  the 
case.  The  symptoms  of  displacement  previously  de- 
scribed may  also  be  observed   after  fracture  of  the   hori- 


FRACTURES  OF  THE  SACRUM.  359 

zoiital  or  descending  ramus  of  the  pubes,  and,  in  addition, 
the  adduction  of  the  thigh  is  more  or  less  restricted. 

Fractures  of  the  ischium  usually  leave  the  bone  notice- 
ably thickened,  and  the  patient  is  unable  to  assume  a 
sitting  posture  for  a  long  time  afterward.  In  these  cases, 
too,  the  nuiscles  of  the  buttocks  and  thigh  undergo 
atrophy. 

Fractures  involving  the  acetabulum  lea<l  to  impaired 
mobility  of  the  hip-joint,  and  not  infrequently  to  com- 
plete ankylosis.  Tiie  latter  is  especially  likely  to  follow 
when  the  heiid  of  the  femur  is  driven  directly  into  the 
acetabulum  by  a  force  acting  from  the  side,  fracturing 
the  acetabulum  on  its  inner  aspect,  or  when  the  acetabu- 
lum is  involved  in  an  extensive  comminuted  fracture. 

Fractures  of  the  pelvis  occasionally  occur  as  a  result  of 
comparatively  slight  degrees  of  violence.  Richter,  for 
instance,  has  reported  a  case  of  fracture  of  the  pelvic  rim 
and  displacement  of  the  sacro-iliac  articulation  due  to  a 
fall  from  a  comparatively  trifling  height. 

The  prognosis  as  to  function  is  most  unfavorable  in 
cases  of  fracture  of  the  acetabulum,  because  of  the  subse- 
quent ankylosis  or  of  the  condition  of  recurrent  dislocation 
of  the  joint,  which  is  a  frequent  sequel  (insurance  allowance, 
33^^  to  75^).  There  are,  however,  exceptions  to  this 
rule,  as  is  shown  by  the  cases  cited  further  on. 

Complications,  in  the  shape  of  injuries  of  the  bladder 
and  urethra,  are  also  likely  to  produce  very  troublesome 
sequels. 

Fractures  of  the  iliac  bones  cause,  as  a  rule,  the  least 
functional  disal)ility. 

Average  insurance  allowance,  from  0  to  20^. 


Fractures  of  the  Sacrum. 

Fractures  of  the  sacrum  occur  in  consequence  of  such 
accidents  as  being  caught  under  heavy  weights  or  being 
run  over,  or  they  are  indirectly  caused   by  a  fall  on  the 


300  DISK  A  SES  CA  USED  BY  A  CCI DENTS. 

buttocks.     These  fractures  are  very  often  seen  in  connec- 
tion with  fractures  of  the  pelvis. 

The  symptoms  consist  in  pain,  radiating  toward  the 
pelvis  and  thighs,  and  in  difficulty  in  walking  and  stoop- 
ing. If  the  fracture  is  complicated  by  injury  of  the 
sacral  cord,  the  sncral  nerves,  or  the  cauda  equina,  we 
have  to  deal  also  with  both  motor  and  sensory  paralysis 
of  certain  muscles  of  the  outer  side  of  the  foot,  with 
paralysis  of  bladder  and  rectum,  and  with  neuralgic  pains 
radiatint)-  toward  the  thio-hs. 

o  & 

CVts'f  of  fracture  of  the  left  acetabulum  resulting  in  slight  functional  dis- 
ahilitjj. 

A  hod-carrier,  tliirty-two  years  of  age,  fell  with  a  scaffolding  from 
a  height  of  about  nine  feet  on  October  li),  1890.  He  was  treated  for  a 
time  in  the  liospital.  From  January  19  until  March  15,  1891,  he 
attended  my  clinic.  He  was  of  medium  size;  he  walked  with  a  limp 
and  required  a  cane.  The  pehis  was  asymmetric  and  was  depressed 
on  the  left  side.  The  mobility  of  the  hip-joint  was  restricted,  and  the 
left  lower  extremity  appeared  shortened  and  wasted. 

When  discliarged,  the  movements  of  the  hij>joint  had  become 
almost  normal;  there  was  still  slight  crepitation  on  movement,  and 
the  circumference  of  the  left  thigh  measured  two  centimeters  less,  and 
the  left  calf,  one  centimeter  less  than  the  corresponding  part  on  the 
opposite  side. 

Insurance  allowance,  20%.  The  skiagraph  showed  a  well-marked 
fracture  of  the  acetabulum  and  considerable  narro\ving  of  the  left  side 
of  the  true  pelvis. 

Ckwe  of  fracture  of  the  left  ilium. 

A  carpenter,  forty  years  of  age,  fell  from  a  roof  nine  feet  high  on 
Octol)er  24,  1894,  striking  on  the  left  hip  and  on  the  left  side  of  the 
heiul.  He  was  treated  in  the  hosjntal  until  January  V.i,  1895,  and 
sub.sequently  at  home  by  the  physician  of  his  trade-union. 

I  examined  him  on  October  21,  1H9.5.  He  was  a  rather  large  man, 
somewhat  thin,  and  a  very  heavy  drinker.  When  he  lay  on  the  back, 
the  left  side  of  the  pelvis  was  higher  than  that  of  the  right  side,  and 
the  left  leg  appeared  shortened.  Careful  measurement,  however, 
showed  the  length  of  both  extremities  to  be  the  same;  the  left  thigh 
was  rotated  outward.  The  left  side  of  the  pelvis  was  narrowed,  the 
left  anterior  superior  spine  l)eing  placed  2}  cm.  nearer  the  median  line 
tlian  the  right.  The  left  pubic  ]>one,  near  the  symphysis,  was  dis- 
tinctly thickened.  Movement  of  the  hip-joint  was  only  slightly 
affected,  Imt  gave  rise  to  pain.  The  whole  extremity  was  greatly 
atrojjhied,  and  dragged  in  walking. 

The  patient  was  first  conceded  an  insiu-ance  allowance  of  33J%, 
which  was  later  reduced  to  20  % .  In  the  course  of  time  sequels  of  the 
injury  to  the  head,  in  the  fonn  of  hysteric  convulsions,  caused  the 


1 


CASES  OF  FRACTURE  OF  THE  PELVIS.  361 

allowance  to  be  raised  to  75  %  ■  No  improvement  has  taken  place  thus 
far. 

Cane  of  fracture  of  the  left  ilitt))),  teft  ascending  ramus  of  the  ischium, 
and  tuberosity  of  the  ischium  ;  also  crushing  of  the  left  side  of  the  abdomen 
and  testicles  and  double  fracture  of  the  left  femur. 

A  mason,  thirty  years  of  age,  was  standing  on  a  staircase,  which 
gave  way,  causing  him  to  fall  with  it  a  distiince  of  two  and  a  half 
stories.  He  sustained  the  injuries  just  mentioned,  and  was  treated  in 
the  hospital.  The  accident  occurred  in  November,  1886.  I  examined 
him  on  ]\Iay  2,  1890.  He  was  a  man  of  middle  height,  rather  pale  and 
thin.  He  walked  with  difhculty  and  with  the  aid  of  crutches.  The 
left  lower  extremity  was  much  shortened  ;  it  did  not  touch  the  ground 
when  the  patient  stood  upright.  AMien  he  lay  on  the  back,  the  left 
side  of  the  pelvis  was  seen  to  be  higher  than  the  right.  The  whole 
pelvis  was  deformed  ;  the  tuberosity  of  the  left  ischium  was  greatly 
thickened,  being  nearly  the  size  of  a  child's  list.  A  point  of  callous 
thickening  could  also  be  felt  on  the  ascending  ramus  of  the  left  ischium. 
The  muscles  of  the  buttocks  on  the  left  side  were  greatly  atrophied  and 
very  flabbj^,  so  that  the  bone  could  be  distinctly  felt  ;  the  patient  was 
obliged  to  use  a  rubber  cushion  in  order  to  endure  a  sitting  posture. 
The  circumference  of  the  middle  of  the  left  thigh  was  diminished  by 
four  centimeters,  and  the  left  .sciatic  nerve  was  exceedingly  sensitive. 
The  patellar  reflex  was  exaggerated  on  that  side. 

The  patient  received  100%  insurance  allowance  ;  the  fractures  of 
the  femur  had  reunited  very  unfavorably,  and  he  was  imable  to  work, 
either  standing  or  sitting. 

CW.sf  of  dislocation  of  the  right  hip-joint  and  fracture  of  the  right  ascend- 
ing ramus  of  the  ischium.     Sequel,  good  recovery. 

A  hod<iarrier,  fifty-four  years  of  age,  fell  from  a  height  of  one  story 
on  March  23,  1893.  He  was  treated  in  the  hospital  for  seventeen 
days  ;  subsequentlj'  at  his  own  home. 

I  examined  him  on  April  10,  1895.  The  right  lower  extremity  was 
very  slightly  shortened,  the  muscles  of  the  right  thigh  were  atrophied, 
and  the  mobility  of  the  right  hip-joint  was  slightly  impaired.  The 
thickening  and  displacement  of  the  bone  at  the  point  of  fracture  of  the 
avscending  ramus  of  the  right  ischium  were  distinctly  perceptible. 
The  patient  at  first  walked  with  a  limp  and  with  the  assistance  of  a 
cane;  I  happened,  however,  one  day  to  see  him  running  up  a  hill  with- 
out any  difficulty. 

He  received  no  allowance  for  the  injury  to  tlie  pelvis,  but  was  con- 
ceded 25%  for  other  injuries. 

Ca.se  of  fracture  of  the  left  side  of  the  pelvis  {ilium  and  acetabulum). 
Sequel,  recurrent  dislocation  of  the  left  hip-joint. 

A  mason  fell  from  a  ladder  on  June  8,  1897,  sustaining,  among 
others,  the  foregoing  injuries.  He  was  treated  at  home,  where  he  lay 
in  bed  for  eleven  weeks.  On  October  8,  1897,  he  entered  my  hos- 
pital for  treatment.  He  was  a  large  and  very  vigorous  man.  The 
left  shoulder-joint  was  ankylosed  and  the  muscles  of  the  left  arm 
were  atrophied.  On  the  left  side  of  the  chest  the  pleura  was  thick- 
ened.    The  pelvis  was  a.symmetric;  the  left  side  was  raised  above  the 


362  DISEA SES  CA USED  BY  A CCI DENTS. 

right  when  the  patient  lay  on  the  back;  the  left  lower  extremity 
appeared  sliortened,  and  was  rotated  ontward.  Points  of  thickening 
could  be  felt  on  the  ascending  ramus  of  the  left  ischium.  Flexion  of 
the  hip-joint  could  be  carried  to  an  angle  of  120  degrees;  the  total  range 
of  flexion  and  extension  equaled  HG  degrees,  and  all  movement  of  the 
hip-joint  was  painful.  The  left  lo\ver  extremity  ^^■as  atrophied  to  an 
extent  of  two  centimeters.  The  head  of  the  femur  slipped  out  of  the 
acetabulum  whenever  the  patient  moved  at  all  carelessly,  or  even  when, 
in  response  to  the  application  of  electricity,  the  muscles  of  the  thigh 
or  buttocks  contracted  violently.  By  the  aid  of  a  support  which 
retained  the  head  of  the  femur  in  position  the  patient  was  enaVded  to 
walk  very  well  without  a  cane.  The  ankylosis  of  the  .shoulder  having 
been  overcome,  he  was  discharged,  with  an  insurance  allowance  of 
60^. 

Dislocations  of  the  Pelvic  Bones. 

Dislocations  of  the  pelvic  bones  are  a  very  rare  form 
of  injury ;  unless  properly  reduced,  they  give  rise  to 
marked  symptoms. 

The  displacement,  when  one  side  of  the  pelvis  is  in- 
volved, is  very  noticeable ;  the  position  of  the  pelvis  and 
of  the  lower  extremity  is  different  on  the  two  sides,  and  is 
manifested  also  in  the  gait.  Pain  and  atrophy  of  the 
muscles  are  prominent  symptoms. 

The  capacity  for  self-support  is,  as  a  rule,  greatly 
diminished. 

Dislocations  of  the  Sacrum. 

This  lesion  is  usually  seen  in  the  form  of  a  sul)luxation, 
the  sacrum  being  displaced  forward.  The  symptoms  are 
a  constrained  position  of  the  body,  lordosis  and  scolio- 
sis of  the  lumbar  region,  pain  in  the  lumbar  region,  and 
restricted  mobility  of  the  spine  and  lower  extremities. 
Externally,  there  is  a  distinct  depression  of  the  area  nor- 
mally filled  out  by  the  sacrum.  In  addition,  the  muscles 
of  the  thigh  and  buttocks  show  signs  of  atrophy. 


I 


INJURIES  OF  THE  HIP.  363 


2.  INJURIES   AND  TRAUMATIC  DISEASES  OF  THE 
HIP=JOINT. 

(104  Cases.) 

Contusions  and  Sprains  of  the  Hip^joint. 

Contusions  and  sprains  of  tlie  hip-joint  are  caused  by 
falls  on  the  hip,  on  the  great  trochanter,  by  blows  or  kicks, 
or  they  may  be  due  to  the  hip  being  caught  and  com- 
pressed between  two  objects  or  under  falling  walls,  etc. 
The  lesion  in  many  cases  is  soon  followed  by  complete 
recovery.  Sometimes  the  hip  is  slightly  painful,  and  the 
muscles  of  the  hip  and  thigh  remain  atrophied  for  a  time. 

In  light  cases  the  patient  is  but  slightly  incajiacitated 
for  work  ;  the  insurance  allowance  varies  from  0  to  20  ^ , 
exceeding  this  figure  in  more  severe  cases. 

Inflammation  of  the  Intertrochanteric  Bursa. 

This  lesion  is  observed  in  cases  of  severe  contusion  of 
the  hip.  The  symptoms  consist  in  pain  and  swelling, 
restricted  mol^ility  of  the  hip-joint,  and  difficulty  in  walk- 
ing ;  later  on,  in  crepitating  sounds.  The  muscles  of  the 
hip  and  thigh  usually  undergo  atrophy. 

The  insurance  allowance,  after  subsidence  of  the  acute 
inflammation,  varies  from  0  to  20^. 

Simple  Uncomplicated  Sprains  of  the  Hip=]oint. 

This  form  of  injury,  caused  by  sudden  strains,  is  seldom 
met  with,  except  in  the  building  trades,  where  it  occurs 
with  relative  frequency.  It  is  produced  by  a  misstep  in 
crossing  an  open  space,  or  in  mounting  or  descending  lad- 
ders and  stairways ;  a  frequent  cause  is  slipping  while 
carrying  a  heavy  burden  or  when  pushing  a  wheel-barrow, 
etc.  The  injury  leads  to  pain  on  movement  of  the  hip- 
joint  and  to  slight  atrophy  of  the  nmscles  of  the  hip  and 
thigh.  In  the  cases  that  I  have  seen  the  patients  were,  as 
a  rule,  able  to  resume  work  in  from  four  to  six  weeks. 


364  DISEASES  CAUSED  BY  ACCIDENTS. 


Dislocation  of  the  Hip=joint. 

This  is  one  of  the  rarer  forms  of  injury.  It  is  seen  in 
individuals  who  have  been  run  over,  caught  under  faUing 
walls,  etc.,  or  who  have  fallen  from  a  height,  and  is 
always  caused  by  indirect  violence  acting  on  the  trunk  or 
thigh. 

The  symptoms  Avitli  which  we  subsequently  have  to 
deal  in  cases  in  which  reduction  is  practised  are  as 
follows  : 

The  thigh  is  slightly  rotated  outward  or  inward,  in  con- 
sequence of  cicatricial  contraction  of  the  capsule,  the 
direction  of  rotation  and  its  degree  depending  on  the 
location  and  extent  of  the  laceration.  The  nuiscles  in 
connection  with  the  hip-joint — those  of  the  buttocks,  of 
the  thighs,  and,  to  a  certain  extent,  those  of  the  leg — 
appear  atonic  and  atrophied.  The  movements  of  the 
aifected  thigh  lack  the  strength  of  those  of  the  opposite 
side,  and  frequently  produce  distinct  crepitation.  The 
weakness  of  the  limb  is  very  noticeable  for  the  first  few 
weeks,  and  the  patient  often  walks  with  a  limp. 

If  the  dislocation  is  complicated  by  injuries  of  the 
nerves,  recovery  from  the  muscular  atro})liy  will  be  pro- 
portionately delayed.  In  cases  of  backward  dislocation 
the  sciatic  nerve  is  always  badly  contused,  stretched,  or 
strained,  if  not  even  more  seriously  injured. 

The  iunctional  disability  is  greatly  increased  if,  as  hap- 
pens in  very  rare  instances,  the  iliofemoral  ligament  is 
involved  in  the  laceration  of  the  capsule. 

We  sometimes  have  to  deal  with  a  very  serious  com- 
plication in  the  shape  of  a  fracture  of  the  neck  of  the 
femur,  occurring  at  the  time  of  dislocation,  or  possibly 
during  reduction.  The  functional  prognosis  is  thereby 
made  very  grave,  as  the  limb  may  be  rendered  useless  for 
a  long  time,  if  not  permanently. 

Tiie  treatment  consists  of  mcdicomechanical  exercises, 
accompanied    by    massage,    baths,   and    electricity,    with 


J 


DISLOCATION  OF  THE  HIP.  365 

the  aim  of  overcoming  the  ankylosis  and  muscular 
atrophy. 

In  respect  to  the  duration  of  treatment,  from  four  to 
six  weeks  are  usually  required  for  uncomplicated  cases, 
and  a  proportionately  longer  period  Avhen  complications 
exist. 

The  patient,  since  he  can  usually  walk  fairly  well,  is, 
as  a  rule,  not  greatly  incapacitated  for  work.  An  insurance 
allowance  of  25  ^  is  usually  sufficient. 

Case  of  dislocation  of  iJie  left  hip-joint,  followed  by  considerable  func- 
tional disability  at  fist ;  later,  by  marked  improvement. 

A  coachman,  on  May  31,  1897,  was  canglit  under  a  pile  of  flour- 
bags,  which  fell  on  him,  causing,  among  other  injuries,  a  dislocation 
of  the  left  hip-joint.  He  was  treated  in  the  hospital  for  nine  and 
a  half  weeks,  seven  of  which  he  si>ent  in  bed.  Subsequently  he 
attended  a  clinic,  where  he  was  treated  by  massage  and  electricity. 
He  received  a  course  of  treatment  in  my  hospital  lasting  from  April 
17  until  July  10,  1899,  after  which  date  he  attended  my  clinic  until 
September  16,  1899,  when  he  was  tinally  disc-harged.  He  was  treated 
chiefly  for  a  subluxation  of  the  right  acromioclavicular  joint. 

Symptoms. — Pain  in  the  left  hip-joint,  esiiecially  on  climbing  stairs. 
The  left  hip  appeared  somewhat  atrophied  when  compared  with  the 
right,  as  did  also  the  muscles  of  the  thigh.  Flexion  of  the  hip-joint 
on  the  left  side  was  somewhat  restricted ;  with  the  patient  lying  on  the 
back,  the  thigh  could  be  flexed  to  an  angle  of  40  degrees  on  the  left 
side  and  55  degrees  on  the  right  side;  when  standing  upright,  the 
angle  between  the  thigh  and  the  trunk,  when  the  former  was  flexed, 
equaled  only  130  degrees  on  the  left  side  In  comparison  with  90 
degrees  on  the  right  side. 

"SVlien  the  jiatient  resumed  work,  there  remained  only  a  slight 
impairment  of  mobility  of  the  left  hii)-joint. 

Case  of  chronic  synovitis  of  the  left  hijt-joint  folloivinfj  an  accident 
caused  by  a  caving-in. 

A  mason,  twenty-three  years  of  age,  was  caught  in  the  caving-in 
of  an  embankment  on  May  20,  1897.  He  Ava.s  at  first  treated  at  his 
home;  on  August  23,  1897,  he  began  a  course  of  treatment  in  my 
clinic.  The  patient  Avas  a  small  but  vigorous  man.  His  right  lower 
extremity  was  held  flexed  and  was  almost  completely  ankylosed  at 
both  hip-joint  and  knee-joint.  The  muscles  of  the  limb  were  greatly 
atrophied  and  displayed  marked  contractures.  Every  effort  at  move- 
ment caused  pain.  The  thigh  formed  an  angle  of  125  degrees  with 
the  trank;  the  knee  was  fixed  at  an  angle  of  150  degrees.  The  patient 
was  first  treated  by  an  extension  apparatus,  and  suV)sequently  V)y  exer- 
cises, massfige,  electricity,  and  baths.  Later  on,  he  receiAed  a  suppoi't- 
ing  apparatus,  which  lie  still  uses  in  walking.  "Without  its  aid  he  can 
walk  only  Avith  difficulty  and  by  leaning  on  two  canes.     When  dis- 


3(36  DISEASES  CAUSED  BY  ACCIDENTS. 

charged,  the  mobility  of  the  hip-joint  and  of  the  knee-joint  had  con- 
siderably improved,  and  the  limb  wtis  held  less  flexed  than  before. 
Insurance  allowance,  75% 

Traumatic  Coxitis. 

The  symptoms  of  this  tlisorder,  wliich  is  met  with  in 
consequence  ot"  contusions,  falls,  or  kicks  on  the  hip,  or 
when  the  parts  are  crushed  by  more  serious  accidents,  are 
almost  identical  with  the  symptoms  of  nontraumatic  in- 
flammation of  a  similar  nature.  Thiem  asserts,  however, 
that  the  traumatic  form  is  more  likely  to  lead  to  anky- 
losis. Suppuration  never  occurs  in  these  cases.  Other 
symptoms  are  :  flexed  position  of  the  hi})-joint  and  knee- 
joint  ;  aj>parent  shortening-  of  the  limb  ;  pnin  in  the  iiip- 
joint ;  atrophy  of  the  muscles  of  the  whole  limb,  espe- 
cially of  those  of  the  hip  and  thigh  ;  difliculty  in  walk- 
ing ;  and  a  limping  gait. 

Treatment. — The  same  as  of  the  nontraumatic  form. 

Insurance  allowance,  from  60^  to  80^  if  there  is 
marked  difficulty  in  walking;  from  40^  to  60^  in  less 
severe  cases.  If  the  patient  is  able  to  walk  without  a 
cane,  20^  is  sufficient. 

Tu])ercular  inflanmiation  of  the  hij)-j()int  may  be  ex- 
cited by  traumatism  in  individuals  in  whom  tuberculosis 
already  exists  in  latent  form.  It  may  be  manifested 
primarily  in  the  hi})-joint  or  may  appear  there  in  conse- 
quence of  metastasis.  Suppuration  frequently  sets  in 
and  the  joint  may  be  in  large  part  destroyed.  The  course 
of  re(^overy  is  exceedingly  protracted. 


3.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE 
THIQH. 

Injuries  of  the  Thigh  Due  to  Contusions. 

(Ninety  Cases,  Including  Wounds.) 

Simple  contusions  of  the  thigh  due  to  kicks,  falls,  and 
the  like  usually  heal  in  a  short  time.     A  long  course  of 


INJURIES  OF  THE  THIGH.  367 

treatment,  on  the  other  hand,  is  reqnired  for  severe  cases 
of  crushing,  caused  by  being  run  over,  caught  under 
heavy  falling  objects,  etc.  The  hemorrhagic  extravasa- 
tions thus  occasioned  are  slowly  absorbed,  and  the  injury 
is  followed  by  atrophy  of  the  muscles,  especially  marked 
in  the  case  of  the  quadriceps  extensor,  which  is  frequently 
very  resistant  to  treatment. 

Recovery  may  not  take  place  under  from  four  to  eight 
weeks,  or  even  longer.  In  one  case  under  my  care  the 
patient  was  not  able  to  resume  work,  even  to  a  limited 
extent,  for  two  years.  The  cause  of  the  persistent  disa- 
bility often  lies  in  lesions  of  the  vessels  and  nerves  and 
in  sul)cutaneous  rupture  of  the  muscles. 

Malignant  tumors  occasionally  develop  as  a  sequel  to 
severe  contusions  of  the  thigh. 

The  accompany ino;  skia<rraph  (Fig.  63,  p.  369)  shows  a  sarcoma  of 
the  right  femur.  The  patient  was  a  workman,  twenty -two  years  of 
age,  who  had  fallen  from  a  scaffolding  into  a  cellar  from  a  height  of 
about  six  feet.  He  fell  on  his  right  thigh,  which  struck  against  a  beam. 
He  continually  complained  of  pain  in  the  thigh,  which,  however, 
never  became  very  severe.  The  enlargement  of  the  thigh — which,  on 
palpation,  was  found  to  be  due  to  a  hard  tumor  adherent  to  the  bone — 
was  distinctly  visible  when  viewed  from  the  extensor  surface.  A 
skiagraph  taken  four  weeks  after  the  accident  was  indistinct  ;  the  one 
here  reproduced  was  ttiken  four  weeks  later.  Meanwhile  the  patient 
was  declared  by  the  authorities  to  be  unfit  for  military  service.  When 
requested  by  his  trade-union  to  submit  to  an  operation,  he  withdrew 
himself  from  our  ol)servation. 

Subcutaneous  Rupture  of  the  Muscles. 

This  lesion  as  it  occurs  in  the  thigh  is  observed  chiefly 
in  the  extensor  nuiscles,  and  of  these  the  rectus  is  practi- 
cally always  the  one  involved.  The  rupture  occurs  under 
the  same  conditions  as  those  which  produce  the  fractures 
of  the  patella  due  to  muscular  violence.  The  latter 
lesion,  in  the  form  of  a  transverse  fracture  in  the  middle 
of  the  bone,  occurs  much  more  frequently  than  the 
former.  Twenty  of  these  indirect  fractures  of  the  patella 
have  occurred  in  my  practice,  while  I  have  had  to  deal 
with  only  five  cases  of  rupture  of  the  rectus. 


368  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  31. 

Subcutaneous  Rupture  of  the  Semitendinosus. 

A  workman,  forty-four  years  of  age,  slipped  from  a  lieam  on  Sep- 
tember 11,  1896,  and  immediately  felt  a  pain  in  the  left  thigh  poste- 
riorly. When  I  examined  him,  on  December  3,  1896,  I  found  the 
muscles  of  the  left  thigh  in  the  condition  here  depicted.  There  was 
a  rather  long  tumor-like  mass  in  tlie  line  of  the  lower  part  of  the  semi- 
tendinosus ;  the  muscles  of  the  thigh  were  all  slightly  atrophied  and 
the  patient  could  not  flex  the  left  knee  as  vigorously  as  the  right. 
The  circumference  of  the  left  thigh  was  two  centimeters  less  than  that 
of  the  right.  The  patient  complained  more  of  weakness  than  of  pain. 
He  was  treated  for  nearly  four  months  by  massage,  exercises,  and 
static  electricity.  Insurance  allowance,  15%,  which  he  still  re- 
ceives. 


Remote  Symptoms. — A  depression  at  the  point  of 
rnjituro,  marked  atro})liy  of  the  rectus  or  quadriceps 
extensor,  secondary  atrophy  of  the  flexors  and  of  the 
muscles  of  the  leg,  inabiHty  to  extend  the  leg,  and  diffi- 
culty in  walking-. 

A  hod<*arrier,  forty-five  years  of  age,  a  very  large  and  unusually 
powerful  man,  Avlien  placing  his  right  foot  on  one  of  the  lower  rungs 
of  a  ladder  which  he  \\ as  descending,  slipped  in  a  way  to  cause  the 
knee  to  be  suddenly  flexed,  while,  at  the  sjime  time,  he  threw  his  body 
backward  to  save  himself  from  falling.  He  immediately  felt  a  violent 
pain  in  the  lower  third  of  the  right  thigh  anteriorly,  and  was  unable 
to  bear  his  weight  on  that  leg.  The  accident  oc<?urred  on  October  20, 
1890.  AVlien  1  examined  him,  on  Jaiuiary  17,  1891,  I  found  a  distinct 
gap  in  the  rectus  muscle,  in  the  lower  third  of  the  thigh,  a  full  hand's- 
Ijreath  above  the  patella.  The  gap  admitted  two  fingers.  All  the 
extensor  muscdes  had  lost  tone  and  were  greatly  atrophied,  as  were  also 
the  flexors.  The  patient  was  imable  to  extend  the  knee,  and  the  leg 
dragged  in  walking.  For  several  months  he  was  obliged  to  iise  two 
crutches  in  walking  ;  later,  he  used  two  ciines  ;  and  still  later,  only 
one  cane. 

After  a  course  of  treatment  of  massage  and  electricity  lasting  thir- 
teen months  the  patient  was  discharged,  wearing  a  knee-cap.  He 
received  (iOfo  insurance  allowance,  which,  in  November,  1895,  was 
reduced  to  40%,  and  at  the  beginning  of  1897  was  further  reduced  to 
20%.     Since  then  he  has  completely  recovered. 

Wounds  and  Scars  of  the  Thigh. 

Of  the  various  wounds  of  the  thigh  those  which  we 
need  most  to  consider  here  are  the  infected  wound.s,  which 


Tab.:u. 


1  • 


Fi«.  G3. 


24 


370  DISEASES   CAUSED  BY  ACCIDENTS. 

are  followed  by  extensive  suppuration,  necessitating  deep 
incisions.  The  scars  that  result  in  these  cases  are  likely 
to  interfere  very  seriously  with  the  movements  of  the  hip 
or  knee,  according  to  their  location.  Walking  is  in  many 
cases  very  difficult  fV)r  a  long  time  afterward.  Cellulitis 
aifects  the  lower  extremity,  however,  nuieh  less  frequently 
than  the  upper. 

The  more  deeply  the  scar  is  attached,  and  the  nearer 
it  lies  to  the  knee,  the  greater  is  the  loss  of  functional 
power.  Compound  fractures  necessitating  oj)crative  meas- 
ures are  sometimes  followed  by  scars,  which,  by  reason  of 
their  attachments  to  the  bone,  have  an  exceedingly  un- 
favorable eifect  on  the  action  of  the  limb.  Some  patients, 
on  the  other  hand,  particularly  youthful  ones,  suffer  no 
inconvenience  from  the  ])resence  of  the  scars.  It  often 
requires  a  long  time,  })erhaps  years,  for  the  scars  to  free 
themselves  from  their  deep  attachments  and  to  become 
suj)erficial. 

Treatment  by  massage  (stretching),  exercises  on  an 
apjiaratus,  galvanism,  wet  compresses,  and  warm  baths 
are  effective  in  improving  the  condition  of  the  scars. 

The  insurance  allowance  is  proportionate  to  the  func- 
tional disability. 

Fractures  of  the  Femur. 

(148  Cases,  luchidiug  Fractures  of  the  Neck.) 

Considerations  on  Anatomy  and  Function. — The  weight  of  the  body  is 
transmitted  to  the  head  of  the  feiiuir  as  it  rests  in  the  cavity  of  the 
acetxiliuluni.  The  neck  of  the  ])one  forms  an  olitnse  angle  with  the 
shaft,  the  angle  varying  in  different  individuals.  The  ordinary  angle 
is  aI)out  1-10  degrees,  hut  in  a  number  of  bones  I  have  found  it  to 
eqnal  only  rj.")  degrees.  Below,  where  the  neck  unites  with  the  shaft, 
the  angle  is  more  obtu.se  than  above,  where  it  approa<*hes  a  right  angle. 
The  neck  is  also  considerably  broader  below  than  above,  where,  near 
the  head  of  the  bone,  it  becomes  quite  slender. 

The  great  can-ying  power  of  the  neck  of  the  femiu'  is  explained  l)y 
the  internal  structure  of  the  neck  and  head  of  the  bone,  in  which  the 
mathematicid  laws  upon  w  hich  its  strength  is  based  are  clearly  dis- 
played. The  neck  is  constructed  to  icsist  lateral  as  well  as  vertical 
pres,sure,  and  the  arrangement  of  the  cancellous  tissue  accords  with 
this.     Firmness  and  elasticity  are  mingled  in  the  structure  of  both  the 


FRACTURE  OF  THE  NECK  OF  THE  FE3IUR.  371 

neck  and  head  of  tlie  bone.     When  the  limits  of  its  elasticity  are 
exceeded,  fracture  of  the  neck  of  the  femur  is  the  inevitable  result. 

Fractures  of  the  Mead  of  the  Femur. 

This  is  a  veiy  unusual  accident,  and  occurs  only  as  the 
result  of  severe  direct  violence,  such  as  l)eing  run  over,  and 
is  then  associated  with  a  fracture  of  the  pelvis.  In  the 
most  favorable  cases  we  must  anticipate  an  ankylosis  of 
the  hip-joint. 

Fractures  of  the  Neck  of  the  Femur. 

(Thirty- eight  Cases.) 

The  neck  of  tiio  femur  may  be  fractured  by  a  force  act- 
ing perpendicularly  to  the  bone,  such  as  a  fall  on  the  knee, 
or  by  one  acting  transversely,  such  as  a  fall  on  the  hi[^ 
more  especially  on  the  great  trochanter.  The  fracture  may 
also  be  caused  by  tension  of  the  iliofemoral  ligament  when 
the  hip  is  overextended.  Old  persons  are  most  subject  to 
the  injury.  By  reason  of  the  porosity  and  lessened  elasticity 
of  the  bones  in  old  age,  the  fracture  sometimes  occurs  in 
consequence  of  a  very  slight  accident.  But  even  in  strong 
young  men,  showing  no  signs  of  syphilis,  tuberculosis,  or 
rachitis,  a  trivial  cause  may,  under  certain  conditions, 
suffice  to  produce  the  lesion  in  question.  I  have  collected 
six  cases,  some  of  which  concern  very  young  and  extremely 
vigorous  hod-carriers,  and  in  all  of  which  the  fracture  was 
caused  by  a  misstep  or  awkward  movement  when  carrying 
a  heavy  load  on  the  shoulder.  The  lesion  in  all  cases  was 
very  severe,  and  functional  power  was  greatly  impaired. 
(See  Part  I,  Fractures  Incidental  to  Special  Work,  p.  66.) 

The  fractures  due  to  tension  of  the  iliofemoral  ligament 
when  the  hip-joint  is  overextended  have  already  been  re- 
ferred to. 

The  more  trivial  the  accident,  the  more  likely  is  the 
fracture  to  be  overhxjked  ;  the  injury  is  diagnosed  as  a 
contusion  or  sprain  of  the  hip-joint,  and  is  treated  by 
compresses,  inunctions,  hot  baths,  and  massage.     Further 


372  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  32. 

Showing  the  Scars  in  a  Case  of  Compound  Fracture  of  the 
Right  Femur  and  Ilium,  and  Loss  of  the  Left  Testicle,  with 
Excellent  Recovery. 

A  paper-liangvr,  twenty -one  years  of  age,  fell  from  a  fourth-story 
^vindo^v  on  August  9,  181)4,  on  to  a  sharp-pointed  iron  railing,  where 
he  was  held  fast  until,  after  an  hour's  delay,  the  iron  bars  were  tiled 
through.  He  was  removed  to  a  hospital,  where  he  remained  until 
December  10,  1894.  8ubse(iuently  he  came  under  my  care,  and  was 
discharged  in  August,  1895,  with  an  insurance  allowance  of  25%, 
^^liich  was  discontinued  a  few  months  later,  the  patient  having  fully 
reco\ered,  and  being  able  to  work  as  well  as  before  the  accident. 


harm  is  not  infrequently  done  by  advising  the  patient  to 
begin  to  walk  very  soon. 

A  difterential  diagnosis  as  to  intracapsular  and  extra- 
capsular fracture,  or  median  and  lateral  fracture  (Hel- 
ferich),  is  of  great  practical  importance,  since  l)ony  union 
very  rarely  takes  place  after  an  intracapsular  (impacted) 
fracture,  fibrous  union,  or  pseudo-arthrosis,  being  the 
rule  in  these  cases.  The  working  capacity  is  greatly 
diminished. 

Symptoms  of  intracapsular  fracture  subsequent  to 
healing  are  as  folh^ws :  The  patient  is  almost  always 
obliged  to  use  a  cane  or  a  supjwrting  a[)paratus  in  walking  ; 
the  limb  always  appears  shortened,  and  is  frequently 
rotated  slightly  outward  ;  less  frequently,  rotated  inward. 
The  whole  limb,  from  the  buttocks  to  the  sole  of  the  foot, 
shows  signs  of  atrophy.  The  rounding  of  the  hip  over 
the  trochanter  is  frequently  found  to  have  disap])eared, 
owing  to  atrophy  of  the  gluteus  niedius.  Even  the  foot 
may  appear  smaller,  and  the  sole  of  the  foot  is  always 
flabby.  The  knee  is  held  flexed.  At  the  hip-joint  the 
mobility  is  not,  as  a  rule,  greatly  affected,  adhesions  and 
ankylosis  not  being  common  to  this  form  of  fracture. 
Patients  frequently  complain  of  feeling  as  if  there  were  a 
spring  in  the  hip-joint.  X-rays  show  the  neck  of  the 
femur  to  have  disappeared,  the  trochanter  lying  quite  near 


H 


EXTRACAPSULAR  FRACTURE  OF  THE  HIP.        373 

the  acetabulum  (iinj)aeted  fracture).  lu  other  eases  we 
find  the  neck  shortened  and  separated  from  both  the  head 
and  the  trochanter. 

The  external  appearances  in  cases  of  extracapsular  frac- 
ture of  the  neck  of  the  femur  (lateral  fractures  of  Hel- 
ferich),  in  which  the  line  of  fracture  approaches  the  tro- 
chanters, are  frequently  quite  similar  to  the  foregoing;  an 
essential  practical  difference,  however,  lies  in  the  fact  that 
extracapsular  fractures  usually  form  a  bony  union,  the 
growth  of  callus  being,  as  a  rule,  exceedingly  well  marked. 
The  angle  between  the  shaft  and  the  neck  is  usually  de- 
creased, approaching  a  right  angle,  and  causing  the  limb 
to  appear  shortened  in  these  cases  also  ;  the  great  trochan- 
ter is  rotated  outward  and  is  very  prominent.  As  seen  in 
a  skiagraph,  it  lies  further  from  the  acetabulum  than  on 
the  normal  side.  The  apex  of  the  trochanter  is  more  or 
less  elevated  above  the  Roser-N6laton  line,  the  degree  to 
which  the  limb  is  shortened  depending  on  this  point. 
The  mobility  of  the  hip-joint  is  usually  restricted  ;  the 
knee  is  held  flexed  ;  and  the  whole  limb,  including  the 
foot,  is  atrophied.  Patients  usually  ^valk  with  a  limp. 
The  working  capacity  of  the  patient,  although  greatly 
diminished,  is  usually  less  seriously  affected  than  in  case 
of  intracapsular  fractures  in  which  bony  union  does  not 
take  place. 

Another  important  point  of  difference  between  the  two 
forms  of  fracture  deserves  special  attention  by  reason  of 
its  practical  bearing.  The  fragments  in  cases  of  impacted 
intracapsular  fractures,  although  to  all  appearances  firmly 
fixed,  are  quite  likely  to  become  separated  from  time  to 
time.  This  does  not  occur  in  cases  of  extracapsular  frac- 
ture after  union  is  once  established. 

While,  as  a  rule,  in  extracapsular  fractures  the  neck 
becomes  united  to  the  shaft  at  a  less  obtuse  angle  than 
normal,  thereby  depressing  the  pelvis  on  the  affected  side 
and  causing  an  a])parent  shortening  of  the  linil),  the  oppo- 
site occurs  in   rare  instances  :  the  angle  is  widened,  the 


374  DISEASES  CAUSED  BY  ACCIDENTS. 

pelvis  is  raised  on  the  affected  side,  and  the  extremity 
appears  longer  tlian  normal,  necessitating  flexion  of  the 
knee  in  the  npright  position.  The  trochanter  is  bronght 
perceptibly  nearer  to  the  acetabulnm,  and,  as  nsnal,  tlie 
mnscles  are  atrophied. 

In  some  cases  the  original  injury  consists  of  a  fissure  in 
the  l)one.  The  injured  individual  is  conscious  of  pain  in 
the  hip,  and  rests  at  home  for  a  few  days,  the  fracture 
proper  occurring  when  he  again  attempts  to  work.  In 
other  instances  definite  fracture  does  not  take  place  until  a 
considerable  period  has  elapsed,  during  which  the  patient 
has  used  the  leg  as  usual.  It  is  probable  that  ine()m[)lete 
fractures  of  this  kind  are  never  diagnosed  in  time;  the 
patient  is  treated  for  a  contusion  of  the  hip  or  similar  in- 
jury, the  limb  is  not  fV-und  shortened  at  first,  and  a  frac- 
ture is  distinctly  excluded  until,  after  a  time,  a  very  per- 
ceptible degree  of  shortening  is  discovered.  These  cases 
are  met  with  from  time  to  time  in  accident-practice,  and 
in  respect  to  indemnity,  are  very  important. 

It  remains  onlv  to  sj)eak(>f  the  effect  on  functional 
power  of  the  different  forms  of  fracture  of  the  neck  of  tlie 
femur.  It  is  hardly  necessary  to  state  that  functional 
power  is  ])ermanently  impaired  in  cases  of  ununited  intra- 
capsular fracture.  Tlie  chief  cause  of  the  loss  of  power 
lies  in  the  presence  of  tlie  unhealed  fractm-e  itself;  in  ad- 
dition, there  is  atro[)hy  of  the  muscles  of  the  hip  and  of 
those  of  the  extremity.  Even  in  these  cases,  however, 
we  meet  with  exceptions. 

Functional  power  is  also  impaired  after  consolidation  of 
extracapsular  fractures  ;  the  shortening  of  the  extremity 
causes  lameness,  which,  because  of  the  abnormal  position 
of  the  head  of  the  bone  in  the  acetabulum,  and  the  weak- 
ness of  the  joint,  is  not  to  be  overcome  l\y  the  use  of  a 
thick-soled  shoe. 

The  following  muscles  undergo  jirimarv  atrophy  :  the 
glutei,  the  iliopsoas,  the  pyriformis,  and  the  obturators. 
Secondarily,   the  other  muscles  of  the   limb  become  in- 


FRACTURES  OF  THE  FEMUR.  375 

volvecl,  especially  those  of  the  thioh.  If  the  fracture 
heals  aclvantageouslj  and  the  functional  ])ower  of  the 
part  is  satisfactorily  restored,  the  condition  of  the  muscles 
will  improve  proportionately  ;  otherwise,  if  union  does  not 
take  place,  they  usually  remain  permanently  atrophied. 
In  the  majority  of  cases,  however,  some  improvement  of 
functional  power  may  be  expected  in  the  course  of  one  or 
two  years,  even  in  elderly  persons. 

Case  of  impdcicd  frdcturc  of  the  neck  of  the  left  femur^  foUoived  hy  non- 
union. 

A  workman,  forty-seven  years  of  age,  fell  down-stairs  on  September 
3,  1898,  sustaining  a  fracture  of  the  neck  of  the  left  femur.  He  was 
treated  in  the  hospital  up  to  November  14th,  and  subsequently 
attended  my  clinic.  He  was  a  thick-set  man  of  middle  height.  He 
walked  with  a  limp  and  with  the  aid  of  two  canes.  The  middle  of  the 
lower  extremity  ^^■as  quite  edematous.  The  circumference  of  the  thigh 
was  two  centimeters  less  tlian  that  of  the  op^iosite  side.  The  patient 
said  that  in  walking  he  felt  as  if  there  were  a  spring  in  his  hip. 

The  skiagraph  showed  an  ununited  fracture  of  the  neck  of  the  femur 
— apparently  an  intracapsular  fracture. 

When  discharged,  the  circumference  of  the  left  thigh  exceeded  that 
of  the  right  thigh  by  two  centimeters;  the  foot,  however,  had  become 
decidedly  atrophied.  There  was  slight  edema  of  both  limbs,  more 
noticeable  in  the  left  one.  Mo\ement  produced  cracking  sounds  in 
the  left  hip-joint.     Flexion  Avas  some\\hat  restricted  on  the  left  side. 

Insurance  allowance,  fi6|^c. 

Cdne  of  fraelKir  of  the  left  femur  eaused  hy  overe.vteimon  of  the  thigh 
when  plaeiiuj  a  heavy  windlass  on  the  shoulder.     Sequel,  good  recovery. 

A  carpenter,  thirty-seven  years  of  age,  in  placing  a  heavy  windlass 
on  his  shoulder,  on  September  21,  1891,  caiised  an  overextension  of  the 
left  hip-joint.  He  felt  a  sudden  ^'iolent  pain  and  as  if  something  had 
cracked,  like  a  stick  breaking.  He  fell  to  the  ground,  and  had  to  be 
Ciirried  home.  He  was  treated  for  several  weeks  for  a  ' '  sprain  of  the 
hip."     He  then  attempted  to  work,  but  was  unable  to  continue. 

I  examined  him  on  November  15,  1893.  He  was  a  rather  large, 
vigorous  man;  the  left  leg  was  slightly  shortened  and  slightly  rotated 
outward ;  the  muscles  of  the  left  thigh  were  atrophied  to  a  moderate 
degree.  He  was  only  slightly  lame.  A  diagnosis  of  fracture  Avas  not 
made  at  this  time.  He  was  soon  dischai'ged  from  clinical  treatment, 
but  returned  on  December  10,  1H94.  Tlie  muscular  atrophy,  pain,  and 
lameness  had  increased.  A  diagnosis  was  made  of  fracture  of  the  neck 
of  the  femur;  the  patient  was  ])ut  to  bed  and  treated  by  massage  and 
electricity.     He  was  discharged  with  an  insurance  allowance  of  15%. 

Case  of  f met u re  of  the  neek  of  the  left  femur  caused  hy  turning  the  left 
knee  and  orere.vtending  the  hip-joint. 

A  workman,  thirty-three  years  of  age,  wishing  to  take  something 
out  of  a  dra\ver  that  was  placed  high  up  in  the  wall,  mounted  on  au 


376  DISEASES  CAUSED  BY  ACCIDENTS. 

inverted  pail.  The  pail  liegan  to  rf)ek  ami  the  man  fell  so  that  his  right 
foot  slipped  outward  and  his  left  hand  struck  against  the  wall.  He 
immediately  felt  a  \iolent  pain  in  the  left  hip,  and  was  unable  to  walk. 
In  the  hospital  to  A\hieli  he  was  taken  he  wa-s  treated  for  a  sprain  of 
the  hip-joint. 

On  September  1,  1897,  he  entered  my  hospital  for  a  course  of  after- 
treatment.  He  was  a  fairly  large,  vigorous  man;  lie  walked  with  a 
limp  and  used  a  cane.  The  left  lower  extremity  was  greatly  atrophied, 
especially  in  the  thigh,  and  was  slightly  rotated  outward.  The  limb 
felt  somewhat  cold.  The  left  thigh  measured  full  4^  cm.  less  than  the 
right;  the  left  leg  '.i  cm.  less  than  the  right.  Active  movement  in  the 
thigh  was  limited  and  jjainful.  Passive  movements  were  less  affected. 
There  was  no  cre])itation.  Treatment  by  massage  and  electricity 
proved  only  slightly  benehcijil. 

The  skiagraph  showed  an  imi)acted  fracture  of  the  ni'ck  of  the  femur. 
The  neck  of  the  bone  had  almost  disiij  )])eare(l  and  the  head  and  neck  of  the 
bone  were  separated  by  an  almost  \ertical,  light  line;  the  great  trochan- 
ter was  raised  somewhat  above  the  level  of  the  head.  The  patient  was 
disc^harged  on  December  11,  1.^97,  with  an  insui'ance  allowance  of  66j%. 
An  examination  made  on  January  18,  1899,  showed  no  improvement; 
on  the  contrary,  the  muscular  atrophy  had  increased ;  the  circumfer- 
ence of  the  thigh  measured  fully  5  cm.  less  than  that  of  the  opposite 
side.  There  was  crei)itation  on  movement  of  the  hip-joint,  and  the 
patient  still  walked  with  a  ciine. 

Case  of  unifiiitcd  infmcapsular  fracture  of  the  tiecl:  if  the  left  femur. 
Sequel,  pseudo-arthrosis. 

A  workman,  thirty-eight  years  of  age,  slipped  on  an  as])halt  walk, 
falling  over  back\vard.  He  was  treated  for  nine  weeks  in  a  surgical 
institute  for  a  fracture  of  the  neck  of  the  left  femur.  An  extension 
appai'atus  was  empkyyed  for  three  Aveeks;  mud  compresses  were  then 
ap])lied,  and,  finally,  the  treatment  consisted  sinii)ly  of  rest  in  bed. 

I  examined  the  ])atient  and  took  a  skiagra])h  of  him  on  February 
l(i,  1^97.  He  was  a  tall,  thin  man;  in  walking  he  used  two  canes,  and 
the  left  leg  dragged.  The  latter  an  as  greatly  atroi)hied  and  much 
shortened;  it  was  also  rotated  outward,  and  could  be  only  a  little 
raised  from  the  ground.  "When  the  patient  was  lying  downi,  the  great 
trf)chanter  could  be  moved  back  and  forth.  A  skiagraph  showed  the 
trochanter  to  lie  considerably  aliove  the  head  of  the  bone;  the  neck 
was  greatly  shortened,  and  was  di\i(led  into  two  parts  by  a  light  line 
of  fracture  about  five  millimeters  in  width. 

The  patient  received  1()(»'^  insmanee  allowance. 

Cane  offraetiiri'  if  the  uiik  of  the  fi  ft  femur  eanseil  tiij  i  tririal  aeeiilent 
when  earrj/iiifj  a  hoilful  of  stoiie.'i  (  fracture  inciilental  to  spceial  work). 

A  hod-carrier,  forty  years  of  age,  a  very  vigorous  and  perfectly 
liealthy  man,  was  injured  on  August  1,  18R9,  by  a  stone  which  fell  from 
the  fourth  story  of  a  building  and  whicli,  in  rebounding,  grazed  his 
left  hip.  He  immediately  felt  a  violent  pain  in  the  left  hip-joint, 
accompanied  by  a  grinding  sensation,  and  was  unal)]e  to  stand  on  the 
left  leg.  He  carefully  put  down  the  hodful  of  stones,  and  was  carried 
to  a  hosi)itiil  by  his  comrades,  where  he  remained  for  about  two_ 
mouths. 


TROCHANTERIC  FRACTURES.  377 

He  was  treated  by  me  clinically  from  October  31,  1889,  until  March 
20,  1891.  He  was  a  vigorous,  stout  man  ;  he  walked  with  a  crutch 
and  a  cane.  The  left  lower  extremity  \\as  much  shortened  and  atro- 
phied, and  was  rotated  outward.  The  head  of  the  femur  did  not  seem 
to  lie  entirely  in  the  acetabuhim.  The  mobility  of  the  hip-joint  was 
somewhat  restricted.  The  middle  of  the  thigh  measured  11]  cm.  less 
in  circumference  than  the  opposite  side,  even  so  long  as  seven  years 
after  the  accident.  A  skiagraph  showed  an  intracapsular  fracture  ;  the 
trochanters  lay  very  close  to  the  acetabulum,  and  the  apex  of  the  great 
trochanter  was  raised  above  the  head  of  the  bone.  Insurance  allow- 
ance, lo'/e ,  at  which  figure  it  has  remained. 

Another  case  concerned  a  hod-carrier,  thirty-two  years  of  age,  who 
had  always  been  perfectly  strong  and  healthy  ;  he  sustained  a  fracture 
of  the  neck  of  the  right  femur  in  stepping  from  a  ladder  to  a  scaft'old- 
ing  with  a  load  on  his  shoulder.  He  said  that  he  felt  as  if  the  scaffold- 
ing was  giving  waj'  under  his  foot.  Union  was  accompanied  by  a 
marked  degree  of  shortening  and  by  forward  displacement  of  the  per- 
ipheral fragment,  which  appeared  as  a  large  tumor  in  the  right  in- 
guinal region.  There  was,  in  addition,  a  marked  degree  of  outward  rota- 
tion. The  mol)ility  of  the  hip-joint  was  restricted,  the  muscles  were 
atrophied,  and  the  patient  walked  with  a  limp.  Insurance  allowance, 
50%  (fracture  incidental  to  special  work). 

Case  of  fracture  of  the  neck  of  the  right  femur  caused  by  a  trivial  acci- 
dent ichen  carrying  stones  {fracture  incidental  to  special  work). 

A  workman,  fifty-one  years  of  age,  who  ha<l  always  been  in  good 
health,  slipped  with  the  right  foot  from  the  plank  on  which  he  was  walk- 
ing when  carrying  a  hodf  ul  of  stones,  giving  his  hip  an  outward  wrench. 
He  was  at  first  treated  at  hf)me  by  inunctions  ;  three  weeks  later  he  was 
removed  to  a  surgical  institute.  An  extension  apparatus  was  applied 
for  eight  days,  followed  by  massage  and  baths.  He  was  discharged 
after  live  weeks'  treatment,  and  was  subsequently  given  massage  at 
home. 

The  accident  occurred  on  November  12,  1898.  I  examined  him  on 
July  23,  1899.  The  skiagraph  then  taken  showed  an  ununited  inti'a- 
capsular  fracture  of  the  neck  of  the  right  femur. 

Fractures  of  the  Femur  in  the  Region  of  the  Trochanters. 

These  fractures  are  caused  l)y  direct  violence,  in  the 
shape  of  a  fall  on  the  great  trochanter,  and  are  often  con- 
nected with  fractures  of  the  neck  or  with  infratrochanteric 
fractures. 

In  cases  of  transverse  or  oblique  fraetm'es  of  the  great 
trochanter  the  trochanter  is  drawn  upward  by  the  gluteus 
medius  and  minimus,  the  pyriformis,  and  the  quadratus 
femoris,  probably  by  the  first  two  chiefly,  so  that  its  apex 
is  approximated  in  the  pelvis.     The  muscles  in  question 


378  DISEA  SES   CA  USED  BY  A  CC I  DENTS. 

remain  atrophied  for  a  long  time,  and  tlie  movements 
that  tliey  control — namely,  abdnction  and  inward  and 
ontward  rotation — are  restricted  and  weakened. 

An  infratrochanteric  fractnre  necessarily  leads  to  short- 
ening of  the  bone;  hence  with  this  lesion  we  always  find 
an  atrophy  of  the  mnscles  of  the  thigh,  and,  secondarily, 
of  the  leg  and  foot  as  well.  The  npper  fragment  is  drawn 
npward  l)y  the  mnscles  inserted  into  the  great  trochanter. 
The  remote  symptoms  of  this  fractnre  are  :  shortening, 
atrophy  of  the  muscles  of  the  whole  limb,  including  the 
foot,  growth  of  adhesions  in  the  hip-joint  and  impaired 
mobility,  pain  in  the  joint,  cracking  sounds  on  movement, 
and  lameness. 

Insurance  allowance,  as  a  rule,  50^. 

('(D^e  of  fracture  of  the  right  femur  in  the  region  of  the  trochanters. 
Sequel,  an  extreme  degree  of  shorteniii";;. 

AcariJenter,  forty-two  years  of  age,  fell  from  a  scaffolding  two  stories 
high,  on  August  26,  1889,  striking  his  right  hip  on  a  beam  lying 
below.  He  was  treated  in  tlie  hospital  for  thirteen  weeks.  I  examined 
him  on  January  2,  1890.  He  was  a  tall,  rather  slender,  and  tliin  man, 
and  was  extremely  deaf.  He  could  Avalk  with  difficulty  by  the  aid  of 
a  cane  and  a  crutch.  The  right  lower  extremity  was  shortened  to  a 
striking  degree,  and  Avas  greatly  atroi)hied.  Tlie  great  trochanter  was 
exceedingly  prominent.  Movement  of  the  right  hip-joint  was  re- 
stricted. 

A  skiagrai)h,  taken  early  in  1898,  showed  a  peculiar  condition,  the 
line  of  fracture  passing  between  the  trochanters  and  running  outward 
into  a  very  sharp-pointed,  sickle-shaped  notch  about  twelve  cejiti- 
nieters  in  lengtli.  The  shaft  of  the  fenmr  was  impacted  in  the  neck 
of  the  bone,  and  the  ajie.x;  of  tlie  great  trochanter  lay  close  to  the  pelvic 
bone,  jn'obably  being  drawn  upward  ])y  the  musck'S  of  the  buttocks. 
Tlie  total  insurance  allowance,  based  on  the  condition  here  described, 
and  on  the  deafness,  which  was  due  to  a  fracture  of  the  skull,  equaled 
80%. 

In  another  ca.se,  one  of  double  fracture  of  the  right  femur,  in  which 
one  of  the  fractures  involved  the  bone  just  })elow  the  trochanters,  the 
skiagraph  also  sliowed  a  Acry  peculiar  displacenu-nt  of  the  fragments. 
In  uniting,  a  coxa  vara  was  formed,  the  limb  being  slightly  shortened. 
Five  months  after  Injury  33J%  insurance  allowance  was  conceded. 

Fractures  of  the  upper  third  of  the  femur  almost 
invariably  lead  to  shortening  and  to  extensive  formation 
of  callus.     In  addition,    we  find  a  lateral  displacement, 


FRACTURES  OF  THE  FEMUR.  379 

with  more  or  less  well-marked  outward  or  inward  rotation, 
in  proportion  to  the  effect  of  the  violence.  The  hip-joint 
assumes  a  position  of  valgus  or  varus  (coxa  valga  or  coxa 
vara).  The  consequent  abnormal  position  of  the  head  of 
the  femur  in  the  joint  can  be  easily  seen  by  means  of  an 
X-ray  examination. 

Both  forms  of  displacement  of  the  hip-joint  induce 
secondary  displacement  of  the  knee-joint ;  coxa  vara  being, 
as  a  rule,  accompanied  by  a  genu  varum  and  coxa  valga 
by  a  genu  valgum.  Inward  or  outward  rotation  of  the 
foot  and  pes  varus  or  valgus  are  further  sequels. 

Adhesions  are  apt  to  be  formed  in  the  hip-joint,  and 
the  nuiscles  of  the  whole  limb  are  invariably  atrophied. 
Pain  on  movement  of  the  hip  joint  and  lameness  necessi- 
tating the  use  of  a  cane,  often  persist  for  a  long  time. 
Other  associated  displacements  of  the  knee-joints  will  be 
discussed  later  on. 

Treatment. — Since  functional  disorders  of  the  limb, 
especially  of  the  hip-joint,  are  prominent  in  all  these 
fractures,  a  vigorous  effort  should  be  made  to  relieve 
them  or  to  make  them  disapjiear  altogether.  Supporting 
apparatus,  mechanical  exercises,  passive  movement,  mas- 
sage, baths,  etc.,  are  all  in(!luded  in  our  therapeutic 
material. 

It  is  especially  advisable  for  the  patient  to  wear  a  sup- 
porting apparatus,  preferably  the  Hessing-Schienhiilsen, 
as  recovery  is  greatly  hastened  thereby.  For  an  im- 
pacted fracture  of  the  neck  of  the  femur,  for  instance,  a 
supporting  apparatus  is  especially  indicated  in  order  to 
prevent  displacement  of  the  fragments.  When  the  limb 
is  only  slightly  shortened,  it  often  suffices  for  the  patient 
to  wear  a  laced  shoe  with  a  raised  sole.  This,  however, 
does  not  ajiply  to  cases  accompanied  by  great  weakness  of 
the  hip-joint. 

Systematic  massage  of  the  atro])hied  muscles  should  not 
be  neglected.  As  a  rule,  the  supporting  apparatus  can  be 
discarded  at  the  end  of  a  few  mouths,  though  it  is  often 


380  DISEASES  CAUSED  BY  ACCIDENTS. 

difficult  to  persuade  the  patient  to  do  so  ;  he  is  then  in- 
clined to  adopt  a  crutch,  especially  if  much  shortening 
exists.  The  insurance  allowance  is  usually  quite  high  in 
all  these  cases,  from  50^  to  66 1^  being  the  ordinary 
rate. 

Case  of  comminuted  fracture  of  the  rigid  femur.  Sequels  :  marked 
degree  of  shortening  ;  deep  scars,  adherent  to  the  bone  ;  and  stiffness 
of  the  lind>. 

A  workman,  fifty-five  years  of  age,  was  struck  in  the  right  thigh  by 
a  piece  of  wood  on  January  19,  1887.  His  right  ankle  was  caused  to 
turn  outward  and  he  was  thrown  to  the  ground.  He  sustained  a  com- 
minuted fracture  of  the  right  thigli  and  a  fracture  of  both  malleoli.  He 
was  treated  in  the  hospital  for  about  three  months.  I  examined  him  on 
October  21,  1887.  The  right  lower  extremity  was  shortened  and  swol- 
len, and  almost  absolutely  stiff  at  the  knee  and  ankle.  He  could  walk 
with  difficulty,  leaning  on  two  crutches.  On  November  4,  1887,  he 
was  suddenly  seized  by  fever  and  chills,  with  signs  of  inflammation  of 
the  thigh,  which  became  greatly  swollen.  He  was  in  the  h<)si)ital  until 
June  22,  1888.  Deep  incisions  were  made  on  the  extensor  surface  of 
the  thigh,  and  pus  and  splinters  of  bone  were  removed.  I  examined 
the  patient  again  on  June  24,  1888,  and  treated  him  in  myelinic  until 
the  end  of  April,  1889.  The  right  lower  extremity  was  strikingly 
shortened,  being  about  six  centimeters  shorter  than  the  left.  He  com- 
plained of  pain  throughout  the  limb  and  of  numbness  of  the  foot.  He 
was  unable  to  walk  or  to  sit  for  any  length  of  time,  and  standing  was 
still  more  difficult.  On  the  anterior  surface  of  the  thigh  there  was  a 
long  scar,  reiujhing  almost  from  the  inguinal  fold  to  near  the  knee  ;  it 
wjis  adherent  to  the  bone  throughout.  The  thigh  and  leg  were  edem- 
atous, and  the  whole  linil)  was  atrophied.  The  moljility  of  the  hip- 
joint  and  of  the  ankle-joint  was  limited,  and  the  knee-joint  was  com- 
pletely ankylosed.  The  right  ankle  was  much  thickened  and  deformed. 
The  patient  walked  with  the  aid  of  a  crutch  and  a  cane.  He  then 
received  100%  insurance  ;illowance.  An  examination  on  February 
17,  1894,  showed  considerable  improvement  in  respect  to  mobility  of 
the  hip-joint  and  knee-joint,  and  the  scar  was  considerably  less 
adherent.     Insurance  allowance,  33J  % . 

Fractures  of  the  femur  in  its  upper  half  i)resent  a 
very  characteristic  ])(cture  after  union  is  ostahlislied. 

The  symptoms  are  as  follows  :  shortening  of  the  limb, 
especially  of  the  thigh  ;  a  well-marked  callous  thickening 
at  the  point  of  fracture ;  displacement  of  the  fragments, 
which  are  usually  bent  with  the  convexity  directed  out- 
ward ;  genu  varum  or  valgum  ;  outward  or  inward  rota- 
tion ;  atrophy  ;  and  lameness. 


Fig.  G4. 


382  DISK  A  SES   CA  USED  B  Y  A  CCIDENTS. 

Case  of  fracture  of  the  left  femur,  followed  by  shortening,  backward  dis- 
placement,  and  genu  recurvatum. 

A  carpenter,  forty-two  .years  of  age,  is  the  siibject  of  the  accompany- 
ing illustration.  (Fig.  64,  p.  3H1.  )  On  Fel)ruary  11,  1H91,  he  fell 
with  a  scaffolding,  sustaining  the  injuries  mentioned.  The  illustration 
sliows  the  overextension  of  the  knee-joint,  and  also  a  muscle-hernia  at 
the  ijoint  of  laceration  of  the  fascia.  The  dark  shading  of  the  left  leg 
represents  the  venous  congestion  that  was  present.  Insurance  allow- 
ance, 66|%  at  tirst;  subsequently,  50%. 

Case  of  compound  fracture  of  the  right  thigh.  Secjuels  :  marked  degree 
of  shortening  ;  genu  varum  ;  ankylosis  of  hip-joint  and  knee-joint ; 
slight  ankylosis  of  ankle.     ( Fig.  ()5,  p.  3h;{.  ) 

A  carpenter,  thirty-three  years  of  age,  fell  from  a  scaffolding  on 
June  24,  1895.  He  was  treated  in  the  hospital  for  seven  weeks;  an 
extension  apparatus  was  used  for  live  weeks.  He  received  a  course  of 
after-treatment  from  September  19,  1895,  until  June  15,  1896. 
When  discharged,  he  could  bend  the  knee — which  at  the  beginning  of 
treatment  had  been  completely  ankylosed — to  an  angle  of  ll^O  de- 
grees, and  the  hip-joint  to  an  angle  of  70  degrees.  Instirance  allow- 
ance, 60%.  This  comparatively  high  rate  was  based  partly  on  compli- 
cating injuries  (of  head,  etc.).     No  further  improvement  up  to  date. 

Fractures  of  the  lower  third  of  the  femur  have  a 
very  decided  effect  on  the  position  of  the  knee-joint,  which 
is  disphiced  in  ])i'oportion  to  tlie  proximity  of  the  fracture 
to  that  joint. 

The  symptoms  observed  in  connection  with  the  knee- 
joint  subsecpient  to  fractures  of  the  lower  third  of  the 
femur  are  commonly  as  follows  : 

1.  Flexion  of  the  knee-joint  (forward  displacement,  the 
variety  most  frequently  seen).  This  is  a  typical  form  of 
displacement;  the  lower  fragment  is  drawn  downward 
by  the  gastrocnemius. 

2.  Overextension  of  the  knee-joint,  genu  recurvatum 
(backward  displacement,  the  least  frequent  form). 

3.  X-position,  genu  valgum  (inward  displacement,  com- 
paratively often  seen). 

4.  0-]><>!^ition,  genu  varum  (outward  displacement,  com- 
paratively often  seen). 

Genu  valgum  is  usually  associated  with  flexion. 

In  addition  to  the  special  form  of  displacement  of  the 
knee-joint,  the  following  symptoms  are  always  present : 
shortening  of  the  femur,  depression  of  the  pelvis  on  the 


Fig.  65. 


384  DISEASES  CAUSED  BY  ACCIDENTS. 

affected  side,  displacement  in  the  hip-joint  and  ankle-joint, 
and  atrophy. 

The  abnormal  position  of  the  knee-joint  limits  the 
movement  of  the  joint,  even  to  the  point  of  complete  im- 
mobility, and  without  the  joint  itself  being  involved  in  the 
fracture.  Tiie  ankylosis  may  depend  upon  inflammatory 
adhesions  that  are  particularly  likely  to  form  after  com- 
minuted fractures,  or  on  too  prolonged  an  employment  of 
splints.  In  the  latter  case  the  stiffness  can  usually  be 
overcome  if  mechanical  treatment  is  begun  in  time.  If 
delayed  until  after  the  thirteenth  week,  recovery  is  doubt- 
ful ;  at  the  best,  a  long  course  of  treatment  is  required. 
Healing,  in  cases  of  compound  fracture  of  the  femur, 
necessarily  involves  the  growth  of  scar  tissue.  (See  Scars 
of  the  Thigh.) 

Laceration  of  the  fascia  leads  to  the  development  of  a 
muscle-hernia,  which  is,  however,  of  no  practical  func- 
tional imjiortance. 

Fractures  of  the  shaft  of  the  femur  are  usually 
marked  by  a  heavy  growth  of  callus  and  by  shortening 
and  displacement.  As  already  stated,  the  effect  of  the  in- 
juiy  on  the  nearest  joint  is  measured  by  the  proximity  of 
the  line  of  fracture,  the  other  joints  of  the  extremity 
being  secondarily  and  proportionately  affected.  After 
consolidation  has  taken  place  the  part  remains  edematous 
and  cyanotic,  the  cyanosis  descending  further  and  further 
on  the  leg  ;  coldness  and  hyperidrosis  of  the  toes  are  also 
to  be  observed.  The  muscles  of  the  whole  extremity  are 
atrophied,  and  the  skin  is  relaxed  and  feels  withered  ; 
with  advanced  atrophy  it  can  be  lifted  up  in  folds. 
The  knee  remains  enlarged  and  swollen  for  a  longtime,  as 
does  also  the  ankle.  Lameness  is  a  constant  symptom  at 
first ;  patients  use  a  crutch  or  a  cane,  and  are  often  very 
clumsy  in  their  movements  for  a  time. 

These  disadvantages  are  best  overcome  by  systematic 
mechanical  treatment,  consisting  of  massage,  baths,  exer- 
cises,   electricity,   and,  at    night,   Priessnitz'    compresses. 


PSEUDO-ABTHROSIS  OF  THE  FE3IUR.  385 

If  a  plaster  cast  is  worn,  it  should,  if  possible,  be  made 
removable,  in  order  to  permit  of  early  massage.  Other- 
wise, it  is  well  to  apply  the  static  breeze  to  the  whole 
limb  through  the  plaster  cast,  or  possibly  through  the 
boots. 

Spontaneous  fractures  of  the  femur  depending  on 
morbid  conditions  of  the  bone  (locomotor  ataxia,  syphilis, 
tuberculosis,  sarcoma)  may  occur  in  consequence  of  the 
most  trivial  accidents.  Such  fractures  have  been  caused 
merely  by  drawing  on  a  boot,  by  standing  up  quickly,  by 
falling  on  the  floor,  etc.  Healing  takes  place  slowly, 
and  there  is  always  danger  of  recurrence.  The  patient  is 
therefore  greatly  incapacitated  for  work,  and  the  insurance 
allowance  after  recovery  must  be  high — higher  than  after 
fractures  of  normal  bcme. 

Pseudo-arthrosis  of  the  femur  is  due  to  the  same 
causes  that  produce  it  elsewhere.  Unless  caused  by  the 
interposition  of  soft  parts,  the  patient  should  be  supplied 
with  an  appropriate  support,  and  should  be  encouraged  to 
walk  as  soon  as  possible,  as  by  this  method  recovery  can 
most  quickly  be  brought  about. 

The  symptoms  are:  shortening;  in  the  beginning, 
edema  of  the  whole  limb,  including  the  foot ;  edema  in 
the  uninjured  extremity  also  ;  abnormal  mobility  at  the 
point  of  fracture  ;  and  atrophy,  which  is  especially  marked 
below  the  fracture. 

An  insurance  allowance  of  from  70  fc  to  80  ^  is  justi- 
fied, unless  the  patient  is  able  to  walk,  fairly  well  by  the 
aid  of  a  support,  in  which  case  a  somewhat  lower  rate 
may  be  granted. 

Case  of  supracondyloid  fracture  of  the  left  femur.  Sequels,  severe 
functional  disability,  ankylosis  of  the  knee-joint. 

The  accompanying;  illustrations  ( Figs.  66  and  67,  p.  387)  show  the 
enlargement  of  the  left  knee-joint,  the  position  of  flexion,  and  the 
shortening  and  atrophy  of  the  limb.  The  knee  is  completely  anky- 
losed.  Insurance  allowance,  50%.  The  skiagraph  (Fig.  68)  very 
beautifully  shows  tlie  manner  in  which  the  fracture  healed.  The  ujiper 
part  of  the  shaft  of  the  femur  forms  almost  a  right  angle  with  the  con- 
25 


386  DISEASES  CAUSED  BY  ACCIDENTS. 

dyles.  Posteriorly,  the  condyles  are  connected  with  the  shaft  by  a 
bridge  of  callus;  the  patella  is  firmly  fixed  between  the  condyles  and 
the  tibia.  The  patient  in  this  case  was  a  mason,  forty-seven  years  of 
age,  who  had  sustained  the  fracture  in  question  by  falling  down  a 
stone  stairway  ten  or  twelve  steps. 

Case  of  snpracondylold  fracture  of  the  femur,  followed  by  partial 
recovery.  '  (Fig.  69,  p.  389.) 

The  subject  of  this  illustration  was  a  workman,  fifty  years  of  age, 
who  fell  from  a  ladder,  dropping  a  distance  of  six  feet,  on  Augiist  24, 
1896.  The  skiagraph  greatly  reseml)les  the  jireceding  one,  but,  when 
closely  examined,  shows  certain  points  of  difference.  At  first  the 
knee-joint  was  much  enlarged  and  was  swollen  and  stiff.  The  course 
of  after-treatment  that  the  patient  received  in  my  clinic  lasted  from 
November  26,  1896,  until  May  22,  1897.  A\nien  discharged,  there  was 
considerable  improvement;  he  could  fully  extend  the  knee  and  could 
flex  it  to  an  angle  of  70  degrees.  He  was  conceded  an  allowance 
of  30%. 

At  present  the  patient  does  not  limp;  he  can  kneel  down  without 
any  trouble,  and  walks  well. 

CW.se  of  serere  comminuted  nupracondyloid  fracture  of  the  left  femur. 

The  accompanying  illustration  (Fig.  70,  p.  390)  shows  a  patient, 
forty-four  years  of  age,  who  sustained  the  foregoing  injury  by  slipping 
with  the  left  foot  and  falling  to  the  ground.  He  was  treated  at  home 
by  the  application  of  plaster  casts,  the  first  of  which  remained  in  ])osi- 
tion  for  two  weeks,  the  second  for  three  weeks;  massage  and  inunc- 
tions were  then  employed.  I  examined  him  and  took  a  skiagraph  on 
March  24,  1899. 

The  illustration  shows  marked  thickening  of  the  thigh  and  an 
extreme  degree  of  shortening. 

The  skiagraph  showed  the  shaft  of  the  femur  to  lie  between  the 
condyles,  from  each  of  which  a  splinter  of  bone,  about  twelve  centi- 
meters long,  protruded  upward.  The  knee  could  be  flexed  to  an  angle 
of  90  degrees.  The  patient  is  still  under  treatment.  It  has  not  been 
possible  to  learn  of  any  previous  serious  disease  in  this  case,  the 
patient  maintaining  that  he  has  always  been  perfectly  healthy,  except 
that  for  one  year  he  was  ' '  nervous. ' '  He  served  three  years  in  the 
artillery. 


Paralysis  of  the  Thigh. 

Paralysis  of  the  crural  nerve  may  be  caused  by 
traumatism  of  a  severe  nature,  such  as  crushing  of  the 
thigh,  or  by  a  simple  accident,  like  slipping  and  falling 
to  the  ground.  Other  causes  are  tumors,  originating  in 
the  spinal  column,  tumors  of  the  pelvis,  or  a  psoas  abscess. 
Oppenheim  has  reported  a  case  due  to  an  aneurysm  of 
the  femoral  artery. 


Fig.  68. 


I  It;.  fi9. 


390 


DISEASES  CAUSED  BY  ACCIDENTS. 


Symptoms. — Paralysis  of  the  iliopsoas  or  quadriceps 
extensor  and  of  the  sartorius  and  pectineus.  Flexion  of 
the  hip-joint  is  suspended;  the  patient  is  unable  to  rise  from 

a  chair  unassisted,  or  to 
raise  the  ley  when  lying 
on  the  back  with  the 
knee  extended.  The  foot 
drags  in  walking,  and  in 
crossing  a  threshold  it 
has  to  be  swung  annuid 
while  the  toes  are  lifted. 
In  walking  the  w^eight  is 
thrown  on  the  opposite 
knee,  while  the  affected 
one  is  held  away  from  the 
median  line.  The  patel- 
lar reflex  is  lost  and  the 
muscles  are  atrophied ; 
there  is  anesthesia  or 
hyperesthesia  of  the  parts 
supplied  by  the  middle 
and  internal  cutaneous 
and  the  long  saphenous 
nerves  :  namely,  the  an- 
terior and  inner  surfaces 
of  the  thigh,  the  inner 
siile  of  the  leg,  and  the 
iinier  border  of  the  foot 
almost  to  the  great  toe. 

Paralysis    of    the 

trunk    of    the    sciatic 

nerve    of    traumatic 

origin  is  met  with  only 

in  rare  cases. 

Symptoms. — Flexion  of  the  knee  is  suspended  ;   the 

leg  drags  in  walking,  and  the  tip  of  the  foot  can  not  be 

lifted. 


Fig.   70. 


FRACTURES  OF  THE  FEMUR.  391 

Fracture  of  the  Condyles  of  the  Femur. 

This  lesion  is  usually  part  of  a  fracture  of  the  joint,  but 
even  when  the  joint  is  not  involved,  the  injury  is  com- 
monly followed  by  ankylosis.  It  is  most  frequently 
caused  by  a  fall — by  striking  the  knee  on  a  stone  step, 
for  instance. 

Symptoms. — The  knee  is  enlarged,  or,  more  properly, 
broadened  ;  the  joint  contains  an  effusion  for  a  time  after 
consolidation  takes  place  ;  subsequently,  it  becomes  anky- 
losed  and  fixed  in  flexion.  The  limb  is  shortened,  the 
muscles  are  atrophied,  and  the  patient  walks  with  a  limp. 
Genu  valgum  or  varum  is  observed  in  some  cases. 

Treatment. — Recovery  can  be  attained  by  means  of 
massage  and  systematic  passive  movements  when  begun 
early. 

Insurance  allowance  :  if  the  knee  is  ankylosed  in  a 
position  of  extension,  from  60  ^  to  SO'/c;  if  slightly  flexed 
(about  160  degrees),  50^;  if  much  flexed,  from  70  fo  to 
80  f,. 

Case  of  paralysis  of  the  right  thigh  {crural  nerve,  quadriceps  muscle) 
caused  by  a  slip  and  a  misstep. 

A  mai-ble-]iolisher,  sixty-five  years  of  age,  in  lifting  a  heavy  sack 
filled  with  soot,  slipped,  and  in  so  doing  stepped  on  a  small,  sharp 
stone,  thereby  forcibly  extending  the  right  liip.  He  felt  a  violent  pain 
in  the  thigh,  and  was  unable  to  lift  the  leg.  He  was  treated  at  home 
for  neuritis,  or,  ratlier,  for  concussion  of  the  spinal  cord  and  intramen- 
ingeal  hemorrhage. 

I  examined  him  on  December  14,  li^96.  The  right  knee  was  flexed 
at  an  angle  of  165  degrees  and  was  ankylosed  in  that  position.  The 
right  gluteofemoral  crease  and  the  muscles  of  the  right  thigh  were 
atrophied,  especially  the  quadriceps.  There  was  slight  edema  of  the 
right  leg  and  foot.  The  riglit  patellar  reflex  was  lost  and  there  was  a 
considerable  degree  of  anesthesia;  pin-pricks  were  not  perceived.  The 
patient  was  unable  to  lift  the  leg  when  it  was  extended,  and  in  cross- 
ing a  tlireshold  was  oldiged  to  swing  the  leg  over.  There  was  marked 
anesthesia  of  the  sole  of  the  foot.  The  patient  walked  with  difficulty 
and  by  using  a  cane.  The  following  cutaneous  nerves  were  involved 
in  the  paralysis  :  anterior  crural,  peroneal,  anterior  tibial,  musculo- 
cutaneous, and  communicans  peronei. 

The  patient  was  discharged  on  August  26,  1897,  with  an  insurance 
allowance  of  66|%,  afterward  raised  by  the  court  to  85%,  at  which 
rate  it  has  continued. 


392  DISEASES  CA USED  BY  A CCI DENTS. 


4.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE  KNEE. 

(263  Cases.) 

Considerations  on  Anatomy  and  Function. — The  knee-joint  is  capable 
of  the  following  movements  : 

1.  Flexion. 

2.  Extension. 

3.  Inward  rotation  when  the  knee  is  flexed. 

4.  Outward  rotation  when  the  knee  is  flexed. 

5.  Rotation  of  the  tibia  at  the  beginning  and  end  of  flexion  and 
extension. 

Flexion  is  produced  by  the  seniitendinosus,  the  semimembranosus, 
and  the  biceps  (supplied  by  the  sciatic  nerve).  During  flexion  the 
patella  glides  downward. 

Extension  is  produced  by  the  quatlriceps  extensor  (supplied  by  the 
anterior  crural  nerve).     During  extension  the  patella  glides  upward. 

The  beginning  and  end  of  flexion  and  extension  are  both  accom- 
panied by  rotation.  In  addition  to  its  action  as  a  flexor,  the  biceps 
serves  to  rotate  the  leg  out\\ard,  while  inward  rotation  is  executed  l)y 
the  semitendinosus  and  semimembranosus.  Flexion  can  be  carried  to 
an  angle  of  about  40  degrees  or  something  over.  This  angle  is  essen- 
tial in  order  to  kneel  for  any  length  of  time  with  ease,  while  occasion- 
ally changing  position  by  resting  the  buttocks  on  the  heels.  An  angle 
of  60  degrees  to  70  degrees  suffices  for  kneeling  ordinarily.  A  com- 
fortable sitting  posture  calls  for  an  angle  of  120  degrees  at  the  knee. 

The  articular  surface  of  the  patella  terminates  a  finger's  width 
above  the  apex  of  the  bone;  the  roughened  portion  below  is  filled  in 
by  fat  and  by  the  subpatellar  bursa;  this  bursa  never  connnunicates 
with  the  knee-joint.  The  capsule  of  the  joint  is  attached  to  the  per- 
iphery of  the  articular  surface,  which  is  covered  by  a  cartilage,  and 
also  to  the  anterior  margin  of  the  femur.  Under  the  tendon  of  the 
quadriceps  extensor,  in  front  of  the  lower  end  of  the  femur,  lies  the 
subcrural  bursa,  Avhich  invariably  communicates  with  the  joint,  and 
A\hich  sometimes  extends  a  handbreadth  or  more  upward  on  the 
femur.  It  is  occasionally  divided  into  compartments,  some  of  which 
may  be  entirely  separated  from  the  others.  The  extensor  tendon  is 
closely  attached  to  this  bursa. 

The  capsule  of  the  joint  is  reinforced  anteriorly  and  laterally  by  the 
aponeurosis  of  the  knee-joint,  derived  from  the  quadrioe])s  extensor, 
while  internally  it  is  additionally  strengthened  by  the  internal  lateral 
ligament,  to  which  it  is  firmly  adherent.  The  internal  lateral  liga- 
ment expands  as  it  passes  downward,  and  is  firmly  attached  to  the  in- 
ternal semilunar  fi))rocartilage,  into  which  its  jiosterior  fibers  are 
inserted.  The  anterior  ])ortion  of  the  ligament  is  continued  down- 
ward as  a  separate  band,  to  be  inserted  into  the  tibia.  The  external 
lateral  ligament  is  separated  from  the  capsule,  or,  rather,  from  the 
external  semilunar  fibrocartilage,  by  the  tendon  of  origin  of  the  popli- 
teal muscle,  which  arises  from  the  popliteal  depression  on  the  external 
condj'le   of   the  femur.      The   posterior   portion  of   the   ligament   is 


ANATOMY  OF  THE  KNEE  JOINT.  393 

inserted  into  the  head  of  the  fibuhi.  The  Literal  ligaments  are  put  on 
the  stretch  during  extension  of  the  joint;  they  serve  to  fix  the  joint, 
and  they  ])revent  the  movements  of  rotation,  which  can  be  executed 
when  the  joint  is  flexed.  The  capsule  of  the  joint  is  reinforced  pos- 
teriorly by  fibers  derived  from  the  tendon  of  the  semimembranosus, 
which  have  received  the  name  of  the  ol)lique  popliteal  ligament.  The 
bursa  that  lies  under  the  tendon  of  the  semimembranosus  at  the 
point  of  its  insertion  in  the  tibia  is  never  in  communication  with  the 
joint.  The  two  heads  of  the  gastrocnemius  are  attached  to  the 
capsule,  and  the  burste  that  frequently  underlie  them  are  alwaj's 
found  to  communicate  with  the  joint.  The  plantaris,  too,  is  adherent 
to  the  capsule.  There  are  some  thin  points  in  the  capsule  posteriorly 
at  which  it  is  possible  for  ganglia  to  develop. 

The  popliteal  artery  and  vein  pass  down  close  to  the  posterior  \\all 
of  the  capsiile,  separated  from  it  only  by  the  lil)rous  tissue  surround- 
ing the  vessels,  wliile  the  popliteal  nerve  is  placed  more  superficially. 

In  the  knee-joint  are  found  the  two  crucial  ligaments,  Avhich  arise 
in  the  sjime  lateral  plane  and  are  inserted  respectively  in  front  of  and 
behind  the  spinous  process  of  the  til)ia  in  the  same  anteroposterior 
plane.  Thus  they  cross  each  other  both  from  before  backward  and 
from  side  to  side,  and  are  wound  about  each  other  in  a  spiral  fashion. 
The  anterior  crucial  ligament  helps  in  preventing  overflexion ;  the  pos- 
terior is  put  on  the  stretch  bj'  extension,  thereby  limiting  this  move- 
ment. 

The  head  of  the  tibia  supports  the  two  semilunar  fibrocartilages, 
which  are  attached  by  their  convex  borders  to  the  capsule  of  the  joint, 
while  their  sharp  concave  borders  look  toward  the  spinous  process  of 
the  tibia,  to  which  they  are  anteriorly  and  posteriorly  attached.  The 
two  fibrocartilages  are  connected  in  front  by  the  so-called  transverse 
ligaments  of  the  knee.  The  internal  tibrocartilage  is  lower  and  less 
curved  than  the  external. 

On  eacli  side  of  the  patella  there  is  a  fold  of  synovial  membrane, 
inclosing  adipose  tissue,  called  the  ligamentum  alaria;  the  two  unite 
near  the  femur  to  form  the  ligamentum  mucosum.  A  synovial  pouch 
is  thus  formed,  directed  upward  and  backward,  in  which  foreign  Ijodies 
may  sometimes  be  lodged,  without  producing  any  irritation.  The  lig- 
amentum mucosum  frequently  di\ides  the  lower  part  of  the  knee-joint 
into  two  lateral  spaces,  which  merge  a))ove  into  one;  or  we  can  distin- 
guish two  spaces  in  the  joint,  one  lying  above  the  other.  The  lower 
space,  which  is  somewhat  the  longer,  corresjjonds  in  shape  to  the  semi- 
lunar fibrocartilages,  the  upper  is  more  pouch-like. 

The  synovial  membrane  lining  the  knee-  joint  is  richly  supplied 
with  synovial  fringes,  some  of  which  are  of  very  large  size  ( jjliysiologic 
crepitation ) . 

A  bursa  communicating  with  the  joint  is  invariably  found  iinder 
the  tendon  of  the  popliteus  muscle  at  its  point  of  origin.  The  nuiscle 
is  always  closely  attached  to  the  joint-capsule,  and  the  bursa  is  ex- 
tended iinder  the  muscle  down  to  the  superior  ti))iofiI)ular  articulation, 
with  which,  in  rare  instances,  it  may  communicate.  In  such  a  case 
the  knee-joint  and  superior  tibiofibular  joint  are  connected;  normally, 


394  DISEASES   CAUSED  BY  ACCIDENTS. 

however,  they  are  entirely  separate.  The  prepatellar  bursa,  which,  as 
its  name  indicates,  lies  in  front  of  the  patella,  never  conunuuicates 
with  the  joint;  occasionally,  more  than  one  bursa  is  developed  in  this 
situation. 

The  tibia  and  head  of  the  fibula  are  closely  and  firmly  united  liy 
the  superior  tilnofibular  articulation,  the  capsule  of  which  is  strength- 
ened by  anterior  and  posterior  ligaments.  Normally,  this  articulation 
is  completely  isolated. 


Contusions  of  the  Knee=joint. 

(175  Cases.) 

The  effects  of  contusions  caused  by  falls,  blows,  or 
kicks,  or  when  the  knee  is  caught  and  compressed  be- 
tween two  objects,  may  be  displayed  in  an  inflammation 
of  one  of  the  numerous  bursae  around  the  knee  or  of  the 
knee-joint  itself.  It  is  with  the  latter  class  of  lesions 
that  we  are,  for  the  moment,  here  concerneil. 

The  symptoms,  after  the  acute  stage  has  passed,  are  : 
swelling  ;  presence  of  an  effusion  ;  moderate  heat  in  the 
joint;  possibly  fixation  of  the  knee  in  flexion;  atrophy 
of  the  muscles  connected  with  the  knee,  particularly  of 
the  quadriceps,  but  also  involving  the  flexors  and,  to  a 
certain  extent,  the  muscles  of  the  leg.  These  symptoms 
persist  for  a  long  time.  If  the  effusion  is  absorbed,  the 
capsule  of  the  joint  will  be  found  thickened  on  palpa- 
tion. 

Many  cases  show  no  signs  of  heat  or  swelling  in  the 
morning,  while  in  the  evening  the  joint  appears  very  hot 
and  swollen  and  contains  an  effusion.  Such  cases  are  not 
to  be  looked  upon  as  cured,  l)ut  should  remain  under 
treatment.  If  a  patient  complains  of  his  knee  being 
swollen  at  night,  another  examination  should  by  all  means 
be  made  at  that  time. 

Later  si/mpfoms :  restricted  mobility  of  the  knee-joint, 
cracking  sounds  on  movement  after  the  effusion  is  entirely 
absorbed,  feeling  of  fatigue,  and  pain. 

Treatment. — Rest ;  immobilization  by  means  of 
splints,  the  knee  being  extended  as   far  as  possible,  and 


SPRAINS   OF  THE  KNEE.  395 

suspended  if  feasible ;  in  addition,  eooling  compresses, 
cold  douches,  Priessuitz'  compresses,  or  compresses  wet 
with  a  solution  of  acetate  of  aluminium,  and  acupuncture 
are  to  be  recommended. 

Subsequently,  massage  of  the  muscles  of  the  thigh  and 
leg,  as  well  as  of  the  knee  itself,  and  electricity,  should  be 
employed.  In  walking,  it  is  often  necessary  for  the 
patient  to  wear  an  elastic  knee-cap. 

The  insurance  allowance  while  the  knee  remains  weak 
and  the  muscles  continue  atrophied  is  usually  estimated  at 

Sprains  of  the  Knee-joint. 

(Fifty-five  Cases  of  Pure  Sftrains.) 

Sprains  of  this  joint  may  be  caused  by  falling  on  the 
knee  or  on  the  feet,  and  by  kicks  on  the  knee,  the  popli- 
teal space,  or  the  leg  near  the  knee  ;  they  also  occur  as  a 
result  of  caving-in  accidents,  of  springing  from  a  carriage 
or  from  a  flight  of  steps,  or  of  sim])ly  turning  the  knee 
(usually  inward),  and  similar  accidents. 

The  sprain  is  accompanied  by  strain  or  partial  rupture 
of  the  ligaments  of  the  joint,  as  well  as  of  the  capsule, 
bursse,  and  tendons.  AYe  sometimes,  for  example,  find  a 
partial  or  complete  rupture  of  the  internal  lateral  ligament 
together  with  a  partial  tear  of  the  semilunar  fibrocartilage 
at  the  point  at  wliich  the  ligament  is  inserted  into  it. 

The  symptoms  are  swelling,  synovial  effusion,  and 
fixed  position  of  the  joint,  as  in  cases  of  contusion.  In 
addition,  the  internal  condyle  of  the  femur  is  often  found 
to  project  distinctly  when  the  knee  is  flexed,  just  as  if  it 
had  been  fractured  and  displaced  and  had  healed  in  that 
position.  If  a  skiagraph  is  taken,  we  can  see  that  the 
spinous  process  of  the  tibia  does  not  lie  in  the  intercon- 
dyloid  notch  of  the  femur  ;  the  prominence  of  the  internal 
condyle  is  also  shown.  This  condition  of  subluxation  is 
characteristic  of  a  large  proportion  of  sprains  of  the  knee- 
joint.    The  more  seriously  the  internal  lateral  ligament  is 


396  DISEASES  CAUSED  BY  ACCIDENTS. 

torn,  the  further  can  tlie  bones  be  separated  on  the  inner 
side  of  the  joint  (loose-jointedness).  This  causes  a  weak- 
ness of  the  knee  and  considerable  difficulty  in  walking. 
Patients  learn  to  hold  the  knee  fixed  as  much  as  possible, 
in  order  to  avoid  turnino;  it  when  they  walk. 

The  longer  the  inflammation  and  effusion  persist,  the 
louder,  as  a  rule,  is  the  subsequent  crepitation  in  the  joint. 
The  rubbing  sounds  are  due  to  the  proliferation  of  the 
synovial  fringes,  which  in  the  knee-joint  are  normally 
present  in  large  number,  and  which  increase  in  size,  as 
well  as  in  number,  when  the  effusion  subsides.  They  sel- 
dom, however,  have  any  influence  on  the  action  of  the 
joint.  The  nuiseles  of  the  thigh,  especially  the  quadri- 
ceps, remain  atrophied  in  proportion  to  the  duration  of  the 
effusion.  The  atrojihy  of  the  vastus  internus  is  often  the 
most  striking.  I  have  found  the  atrophy  of  the  quadri- 
ceps to  last  for  two  years,  or  even  longer,  after  a  sprain. 
Patients  do  not,  as  a  ride,  complain  of  much  pain  in  the 
later  stages  of  the  inflammation. 

Treatment. — The  same  as  that  for  contusions.  In 
addition,  if  loose-jointedness  be  developed  in  consequence 
of  rupture  of  one  of  the  lateral  ligaments,  a  jointed  support 
should  be  worn  for  walking.  The  course  of  treatment  re- 
quired, which  for  some  cases  of  contusion  covers  a  consid- 
erable period,  is  apt  to  be  even  more  protracted  when  it  is 
a  question  of  recovery  from  a  sprain.  Even  slight  exertion 
is  likely  to  bring  on  a  relapse,  with  renewed  swelling  and 
effusion,  demanding  additional  treatment. 

Insurance  allowance,  from  20^  to  33^^. 

Partial  Rupture  of  the  Ligamentum  Patellae. 

This  lesion  occurs  in  connection  with  s])rains,  when,  for 
example,  the  knee  is  turned  or  gives  way  suddenly  when 
it  is  overextended.  The  injury  to  the  ligament  leaves  the 
whole  extensor  apparatus  (quadriceps  including  liga- 
mentum  patelhe)  relaxed  and  the  knee  w^eak,  while  the 
muscles  may  remain  atrophied   for  years.      Primarily,  the 


BURSITY  OF  THE  KNEE.  397 

quadriceps  is  affected  ;  secondarily,  the  atrophy  also  in- 
volves the  other  muscles  of  the  thijj-h. 

A  carpenter,  twenty-five  years  of  age,  slipped  on  a  smooth  plank ; 
his  knee  gave  way  and  he  fell  on  his  kick.  He  felt  a  pain  in  the  knee 
and  was  unahle  to  rise.  An  effusion  took  place  into  the  joint.  A 
skiagraph  taken  somewhat  later  showed  the  partial  rupture  of  the  liga- 
mentum  patellaj  and  the  displacement  of  the  patella  upward.  In 
addition,  the  muscles  of  the  thigh  were  greatly  atrophied  (circumfer- 
ence diminislied  by  four  centimeters),  and  the  knee  was  exceedingly 
weak.  The  patient  was  able  to  extend  liis  knee  to  145  degrees,  and  to 
flex  it  to  55  degrees.  The  patellar  reflex  was  lost.  Insurance  allow- 
ance, 50^. 

Complete  Rupture  of  the  Ligamentum  Patellae. 

This  lesion  is  seen  even  less  frequently  than  the  preced- 
ing. It  occurs  under  the  same  conditions  as  do  the  frac- 
tures of  the  patella  that  are  produced  by  muscular  action. 

The  symptoms  subsequent  to  the  acute  stage  are  :  eifu- 
sion  ;  swelling  ;  and,  unless  the  ruptured  tendon  is  sutured, 
loose-jointedness  ;  and  an  extreme  degree  of  atroj^hy  of  the 
quadriceps.  The  knee  feels  weak  and  insecure,  as  does 
the  whole  limb,  and  the  patient  is  unable  to  extend  the 
knee  or  to  fix  the  patella. 

Treatment. — The  tendon  should  be  sutured  (Plel- 
ferich's  method)  in  all  cases.  In  other  respects  the  treat- 
ment is  the  same  as  for  sprain. 

Injuries  of  the  Bursse  of  the  Knee. 

The  bursae  are  sometimes  injured  in  cases  of  contusion 
or  sprain  of  the  knee-joint.  When  a  communication 
exists  between  the  affected  bursse  and  the  knee-joint,  we 
find  a  diffuse  effusion,  making  the  outlines  of  the  patella 
indistinct.  The  symptoms  in  such  cases  are  identical 
with  those  of  a  synovitis  of  the  knee.  When  no  such 
communication  exists,  it  is  possible  for  the  exudate  in  the 
acute  stage  of  the  bursitis  to  break  through  into  the  joint. 
The  pain  usually  disappears  before  the  subacute  or  chronic 
stage  is  reached,  unless  melon-seed  bodies  should  develop, 
as  frequently  happens  when  the  prepatellar  bursa  is  in- 


398  DISEASES  CAUSED  BV  ACCIDENTS. 

volved.  In  other  respects  this  bursa  gives  less  trouble 
than  any  of  the  others.  When  one  of  the  isolated  bursse 
is  attacked  by  inflammation,  the  symptoms  vary  somewhat, 
according  to  the  location.  In  case,  for  instance,  of  a  pre- 
patellar hygroma  the  quadriceps,  after  absorption  of  the 
effusion,  may  show  no  appreciable  evidences  of  atrophy, 
while  it  is,  as  a  rule,  noticeably  affected  by  a  hygroma 
under  the  tendon  below  the  patella. 

Treatment. — AV  hen  the  effusion  is  absorbed,  massage 
and  electricity  should  be  employed,  and  a  knee-cap  should 
be  ordered.      Exertion  is  likely  to  produce  a  relapse. 

Insurance  allowance,  from  20  ^  to  25  ^ . 

In  one  case  under  my  observation  the  patient,  a  carpenter,  forty- 
eight  years  of  age,  suffered  from  a  bursitis  under  the  lieads  of  the  gas- 
trocnemius, brought  on  by  twisting  tlie  knee,  in  January,  1898.  A 
tense  elastic  tumor  could  be  felt  under  the  heads  of  the  muscle;  the 
knee-joint  was  swollen  and  contained  an  effusion;  it  was  also  weak, 
and  its  mobility  was  restricted.  The  muscles  were  atrophied  and  the 
leg  was  edematous.  The  patient  was  under  treatment  from  August 
27,  18f)8,  liefore  which  date  he  had  not  obtained  medical  advice,  until 
July  28,  1899.     Insurance  allowance  at  first,  83j  fo . 

Wounds  and  Scars  of  the  Knee. 

AVounds  of  the  knee  are  met  with  in  carpenters  and 
wood-choppers,  as  the  result  of  a  blow  from  an  ax  or 
hatchet ;  punctured  wounds  caused  by  a  sharp  instrument, 
such  as  a  chisel,  are  likewise  seen.  As  such  wounds  are 
likely  to  extend  deeply  into  the  tissues,  and  to  involve 
the  bone,  subsequently  forming  cicatricial  adhesions  with 
the  latter,  their  effect  on  the  functional  action  of  the  joint 
becomes  very  serious. 

The  process  of  healing  and  the  subsequent  effect  of  the 
scar  depend  largely  on  the  question  of  infection  of  the 
wound.  Punctured  wounds  which  directly  pierce  the 
ca])sule  of  the  joint  may  be  very  quickly  followed  by  a 
suppurative  synovitis.  Even  simple  contused  wounds 
may  lead  to  a  cellulitis,  and  subsequently  to  ankylosis, 
the  latter  depending  on  the  operation-scars,  as  well  as  on 
iutra-articular  adhesions.     Extensive  scars  situated  over 


WOUNDS  OF  THE  KNEE.  399 

the  knee  or  close  to  it  limit  its  action  to  a  very  consider- 
able degree.  As  a  rule,  the  patient  finds  it  easiest  to  keep 
the  knee  slightly  flexed,  on  whatever  part  of  the  knee  the 
scar  is  situated.  Unless  the  knee  is  moved  with  some 
caution,  the  scars  are  very  likely  to  break  open.  This  is 
especially  the  case  when  the  scar  lies  upon,  and  is  adher- 
ent to,  the  patella,  in  which  situation  it  is  likely  to  be 
injured  by  unguarded  or  frequently  repeated  movements 
of  flexion,  while  scars  of  the  popliteal  region  may  be  torn 
open  by  movements  of  extension.  Similar  effects  are 
seen  when  the  scars  are  situated  at  the  side  of  the  joint. 
In  addition  to  this  constant  danger  of  injury  to  the  scar, 
recovery  is  further  interfered  with  by  more  or  less  atrophy 
of  the  muscles. 

Treatment. — Gradually  to  stretch  the  scar-tissue,  and 
so  to  restore  the  mobility  of  the  joint,  is  the  aim  of  treat- 
ment, and  is  accomplished  by  means  of  warm  baths, 
warm  packs,  massage,  exercises,  and  galvinism.  In  some 
cases  only  a  certain  degree  of  improvement  can  be 
reached ;  the  scars,  hoAvever,  often  become  gradually 
loosened  spontaneously,  although  the  process  may  cover  a 
number  of  years. 

The  working  capacity  of  the  patient,  when  the  mobility 
of  the  joint  is  much  affected,  may  be  very  considerably 
reduced. 

Insurance  allowance  in  light  cases  25^  ;  in  severe 
cases  from  50^  to  60^. 

Punctured  wound  of  the  left  knee  folJowcd  by  suppurative  inflammation 
and  anki/tosis. 

A  carpenter's  apprentice,  seventeen  years  of  age,  injured  his  left 
knee  with  a  chisel.  It  became  swollen  and  inflamed,  and  suppuration 
set  in.  He  was  treated  in  the  hospital  from  September  8,  1894,  until 
January  16,  1895,  the  knee  having  been  opened  in  several  places.  He 
then  attended  my  clinic  until  September  24,  1895.  At  first  the  knee 
was  entirely  stiff,  and  was  set  at  an  angle  of  150  degrees;  when  the 
patient  was  discharged,  it  was  held  at  an  angle  of  170  degrees,  and 
could  be  flexed  to  l25  degrees,  thus  allowing  of  a  flexion  of  45  de- 
grees. The  knee  was  marked  with  deep  scars,  in  part  attached  to  the 
bone;  the  nuiscles  of  the  thigh  were  greatly  atrophied,  the  circumfer- 
ence being  diminished  five  or  six  centimeters.     Insurance  allowance, 


400  DISEASES  CAUSED  BY  ACCIDENTS. 

45%.  At  the  time  of  an  examination  made  on  April  IR,  1898,  no 
noteworthy  improvement  was  apparent;  the  patient  was  unable  to 
kneel. 

Another  case  of  injury  of  the  knee-joint,  caused  by  a  blow  from  an 
ax,  and  followed  by  sujipuration,  concerned  a  carpenter,  fift^'-four 
years  of  age,  who  was  treated  at  home  from  the  day  of  his  accident, 
August  30,  1890,  until  September  22,  1890,  when  he  entered  the  hos- 
pital for  operation,  remaining  there  until  January  24,  1891.  He 
attended  my  clinic  from  April  10,  1891,  until  October  23,  1891.  The 
scars  on  the  knee  were  adherent  to  the  bone,  and  flexion  was  limited 
to  115  degrees,  the  knee  being  held  at  an  angle  of  180  degrees.  The 
muscles  were  atrophied  and  the  patient  was  unable  to  kneel.  Insur- 
ance allowance,  4(t  % . 

Case  of  retracted  cicatrices  over  the  patella  and  on  the  outer  surface  of 
the  knee-joint,  caused  by  a  contusion  and  suppurative  inflammation. 
Sequel,  tubercular  arthritis  of  the  knee;  death  from  pulmonary  tuber- 
culosis. 

A  workman,  twenty-seven  years  of  age,  was  struck  on  the  left  knee 
by  a  stone,  on  November  23,  1891.  The  injury  was  followed  by  swell- 
ing, inflammation,  and  suppuration.  The  patient  entered  the  hospital 
for  treatment;  skin  grafting  was  attempted,  but  was  unsuccessful. 
The  wounds  required  treatment  until  December  30,  1892.  Afterward 
there  was  left  a  deep  scar  extending  along  the  whole  outer  side  of  the 
thigh,  down  to  the  knee.  The  scar  over  the  patella  showed  signs  of 
inflammation,  and  could  be  broken  open  when  the  knee  was  flexed  to 
an  angle  of  85  degrees.  The  leg  was  edematous  and  the  muscles  of 
the  thigh  were  greatly  atrophied.  JMovements  of  the  knee-joint 
caused  crei>itation.  Subsequently,  the  patient  was  able  to  work  and 
to  mount  ladders,  and  received  full  ])ay.  The  first  signs  of  local 
tuberculosis  appeared  at  the  end  of  IHix;,  and  the  patient  succumbed 
to  pulmonary  tuljerculosis  at  the  end  of  1897. 


Dislocations  of  the  Knee=joint. 

(Sixteen  Cases  of  Reduced    Dislocation   Form  the  Basis  of  This 
Section. ) 

Dislocations  of  tlie  knee-joint  are  seldom  seen,  an  ex- 
treme degree  of  violence  being  required  for  their  pro- 
duction. 

The  joint  remains  swollen  for  a  long  time  after  reduc- 
tion, and,  in  addition,  we  find  the  following  symptoms: 
subluxation  of  the  joint ;  loose-jointedness  or  more;  or  less 
complete  ankylosis ;  genu  valgum  or  varum  ;  crepitation 
on  movement ;  atrophy  of  the  whole  limb,  especially  of 
the  (piadriceps ;  restricted  mobility ;  and  difficulty  in 
walkin<j:. 


SUBLUXATION  OF  THE  KNEE.  401 

Treatment. — Stiffness  is  to  be  overcome  by  gymnastic 
exercises,  by  massage,  and  by  passive  movement.  In  case 
of  loose-jointed ness  the  patient  should  be  supplied  Avith  a 
supporting  apparatus. 

The  working  capacity  is  diminished  in  proportion  to 
the  degree  of  stiffness,  of  flexion,  and  of  functional  disa- 
bility ;  the  insurance  allowance  varies  from  33^  ^/o  to 
66ff.. 

Forward  or  backward  dislocations  sometimes  cause  in- 
juries of  the  blood-vessels,  which  may  be  followed  by 
gangrene.     In  the  latter  case  amputation  is  indicated. 

In  a  case  of  dislocation  of  the  left  knee-joint  caused  by  falling  from 
a  wagon,  in  which  the  i)atient  was  a  ]iainter,  twenty-eight  years  of 
age,  the  symptoms  one  year  after  the  injury  (reduced  in  the  hospital) 
were  as  follows:  subluxation  of  the  knee-joint  (the  bones  of  the  leg 
were  displaced  backward  and  outward ) ;  restricted  moljility,  flexion 
being  limited  to  90  degrees  ;  a  slight  degree  of  genu  varum  ;  loose- 
jointedness  ;  muscular  atrophy.  Insiuance  allowance,  33J^.  A  knee- 
support  was  recommended. 

Subluxation  of  the  Knee-joint. 

This  lesion  is  frequently  met  with,  as  a  direct  result 
of  injury  or  as  a  consequence  of  an  angular  deformity 
after  fractures  in  the  vicinity  of  the  joint  or  of  a  re- 
duced di.slocation.  It  is  often  observed  as  a  sequel  to  a 
sprain.  As  a  rule,  we  find  the  internal  condyle  of  the  femur 
displaced  inward  or  the  tibia  somewhat  displaced  back- 
ward.    Other  forms  of  displacement  are  also  met  with. 

Internally,  the  knee-joint  usually  appeare  thickened,  while  the 
knee  Ls  slightly  flexed  and  is  directed  inward  (valgus) ;  less  frequently 
it  is  directed  outward  (varus).  The  muscles  of  the  thigh  and  leg  are 
atrophied,  and  the  knee-joint  is  restricted  in  its  movements,  which  are 
apt  to  remain  painful  for  a  long  time.  In  severe  cases  the  gait  is  much 
affected  and  the  patient  is  unable  to  kneel. 

The  treatment  is  symptomatic.  In  favorable  ca.ses 
functional  power  may  be  regained  in  from  six  to  eight 
weeks,  or  even  sooner,  but  in  others  a  long  course  of 
treatment  is  required.  If  the  symptoms  just  mentioned 
persist,  especially  the  pain,  an  insurance  allowance  of  from 
2G 


402  DISEASES   CAUSED  BY  ACCIDENTS. 

SS^fo  to  60  fc  is  made.      In  light  cases  from    15%    to 
20  fo  is  sufficient. 

Case  of  si(])htx((tw))  of  the  left  knee-joint,  vith  very  profraeted  recovery. 

A  workman,  thiity-ei<;ht  years  of  age,  in  unloading  some  building 
material,  on  May  IG,  1898,  fell  Ijackward  from  the  ^vagon,  catching 
his  left  foot  in  a  chain.  He  was  taken  to  a  hospital,  where  for  two 
weeks  he  was  treated  by  splints,  cold  compresses,  and  massage.  He 
attended  my  clinic  fron'i  August  13,  1898,  until  February  17,  1899. 
The  left  knee-joint  was  fixed  at  an  angle  of  160  degrees  ;  it  was  swol- 
len and  thickened  on  the  inner  side.  The  muscles  of  the  tliigh  were 
greatly  atrophied  (circumference  diminished  four  centimeters);  ex- 
tension was  limited  to  160  degrees  and  flexion  to  90  degrees.  Move- 
ment was  very  painful,  and  tlie  patient  walked  with  great  difficulty, 
leaning  on  a  cane.  When  discharged,  movement  was  considerably 
improved;  there  was  no  pain  and  no  difficulty  in  walking.  Insurance 
allowance,  25%. 

Case  of  subhi.ration  of  the  knec-Joini  icUh  rupture  of  the  internal  Jateral 
ligament. 

The  patient,  who  was  a  workman,  turned  and  dislocated  his  knee 
in  stepping  on  a  stone.  When  1  examined  him,  on  November  17, 
1891,  the  bones  of  the  joint  could  easily  be  drawn  apart  on  the  inner 
side  and  the  muscles  of  the  thigh  were  greatly  atrophied.  The  patient 
wore  a  support.     Insurance  allowance,  45%  ;  later  on,  25%. 

Another  case  concerned  a  mason's  apprentice,  eighteen  years  of  age, 
who  had  dislocated  the  right  knee  by  falling  from  a  scaffolding.  The 
knee  subsequently  became  directed  inward  and  was  overextended. 
Loose-jointedness  was  a  marked  symptom,  and  was  due  to  the  rupture 
of  the  internal  lateral  ligament.  A  knee-support  and  massiige  were 
prescribed.  The  course  of  treatment  in  my  clinic  extended  from  Feb- 
ruary 16,  1891,  until  May  21,  1891.  Insurance  allowance,  33,^%, 
reduced  in  May,  1896,  to  20%,  as  the  patient  was  then  able  to  work 
at  full  pay.     Otherwise  his  condition  remained  unchanged. 

Dislocation  and  Rupture  of  the  Semilunar  Fibrocartilages. 

These  accidents  are  unconnnon  ;  tliey  are  caused  by 
violent  rotation  of  the  end  of  the  femur  mIicu  the  knee  is 
flexed. 

Remote  Symptoms. — Flexed  position  of  the  knee- 
joint  ;  effusion  in  the  joint ;  sometimes  a  slight  local  rise 
of  temperature  ;  snapping  movements,  accompanied  by 
pain  ;  inability  to  extend  the  knee  ;  and  muscular  atroj)hy. 
The  a})pearances  may  so  closely  resemble  those  produced 
l)y  the  presence  of  loose  cartilages  in  the  joint  as  to  make 
a  differential  diagnosis  almost  impossible. 


FRACTURES  OF  THE  PATELLA.  403 

Treatment. — This  consists  in  the  use  of  a  knee-cap  or 
a  supporting  apparatus,  in  massage,  etc.  Insurance  allow- 
ance, from  25^  to  50^. 

Case  of  strain  of  the  left  knee-joint.  Sequels,  aneurj'sm  of  the  popli- 
teal arteiy,  and  gangrene.     Amputation  of  the  leg. 

A  mason,  forty-nine  years  of  age,  slipped  with  his  left  foot  in  lifting 
a  carpenter's  horse,  and  immediately  felt  a  violent  pain  in  the  knee. 
At  first  he  continued  ^\  ork,  l)ut  entered  the  hospital  three  weeks  later, 
where  he  remained  for  three  weeks.  An  operation  (doubtless  incision) 
was  performed;  gangrene  set  in  and  amputation  became  necessary. 
Insurance  allowance,  75  ^ . 

Dislocation  of  the  Patella. 

This  lesion  is  most  frequently  seen  in  the  form  of  an 
outward  dislocation,  a  fact  which  is  easily  understood  if 
we  consider  the  anatomy  of  the  knee. 

Unless  reduced,  the  signs  of  displacement  remain  very 
evident  ;  genu  valgum  is  also  found,  as  a  rule,  and  the 
muscles  of  the  limb,  especially  of  the  thigh  (quadriceps), 
are  atrophied.  The  mobility  of  the  knee  is  usually 
restricted,  but  in  some  cases  is  restored  in  the  course  of 
time. 

For  some  time  subsequent  to  reduction  the  knee  remains 
swollen,  flexed,  and  in  a  position  of  valgus,  while  the 
muscles  regain  their  normal  condition  only  very  slowly. 
Recurrence  of  the  dislocation  is  quite  frequently  observed. 

Partial  dislocations  of  the  patella  are  often  met  with. 

The  treatment  is  symptomatic. 

Insurance  allowance,  from  25^  to  33|^^,  or  more  in 
severe  cases. 

Fractures  of  the  Patella. 
(Thirty-two  Cases. ) 

Indirect  fractures  resulting  from  muscular  action  are  the 
usual  form  of  the  lesion  ;  direct  fractures,  however,  are 
also  met  with.  The  accident  is  usually  caused  by  suddenly 
slipping  and  forcibly  flexing  the  knee,  while  at  the  same 
time  the  body  is  thrown  backward  ;  the  quadiceps  is 
reflexly  contracted,  snapping  the  patella  in  two.     The 


404  DISEASES   CAUSED  BY  ACCIDENTS. 

line  of  fracture  is  transverse.  Less  commonly,  the  eflPect 
of  the  contraction  of  the  muscle  is  manifested  in  a 
rupture  of  the  extensor  tendon  above  or  below  the  patella. 
The  direct  form  of  fracture  is  produced  by  a  fall  on  the 
knee,  strikino;  against  the  edge  of  a  threshold,  for  instance, 
or  by  a  blow  on  the  knee.  These  fractures  are  very  fre- 
quently comminuted.  The  best  results  as  to  functional 
power  are  ol)tained  by  wiring  the  fragments. 

Symptoms : 

(«)  Wheyi  the  fragments  are  united  by  i<uture  and  the 
wound  has  completely  healed. 

There  is  a  scar  on  the  anterior  surface  of  the  knee, 
which  at  first  is  swollen  ;  atrophy  of  the  muscles  of  the 
thigh,  especially  of  the  (juadriccps  ;  secondary  atrophy  of 
the  muscles  of  the  leg  and  foot  ;  restricted  mobility  of 
the  knee. 

In  cases  of  simple  transverse  fracture  the  quadriceps 
may  be  only  slightly  atrophied,  and  soon  recovers  ;  after 
comminuted  fractures  I  have  found  the  atro])hy  to  be 
much  more  marked,  which  may  have  been  ])artly  due  to 
the  fact  tlnit  splints  had  been  applied  for  a  long  time. 

Treatment. — Systematic  exercises,  etc.,  to  restore  mo- 
bility and  to  overcome  atrophy. 

Insurance  allowance,  in  light  cases  20^,  and  in  severe 
cases  33|^  ^  at  first ;  when  improvement  begins  to  appear, 
the  rate  can  be  proportionately  diminished. 

(6)   When  fibrous  union  Jias  taken  ^ib ice. 

The  fragments  are  separated,  in  some  cases  so  much  so 
that  the  hand  can  be  laid  between  them  when  the  knee  is 
flexed  ;  the  muscles  of  the  whole  limb  are  atrophied,  the 
atrophv  being  most  pronounced  in  the  case  of  the  quadri- 
ceps ;  loose-jointed ness,  inability  fully  to  extend  or  flex 
the  knee  and  disturbances  of  gait  are  also  manifested. 
When  he  puts  the  foot  to  the  ground  in  walking,  the 
patient  usually  holds  the  knee  stiff  and  away  from  the 
median  line.  Functional  })Ower  is  not  lost  unless  the 
lateral  ligaments  are  ruptured.     A  bad  prognosis  obtains 


Fig.  71. 


406  DISEASES  CAUSED  BY  ACCIDENTS. 

for  cases  complicated  Ijy  rupture  of  the  lateral  ligauieuts, 
or  for  those  in  which  the  lower  fragment  becomes  wedged 
in  between  the  femur  and  tibia,  and  unites  in  this  position. 
In  the  former  instance  the  power  of  extension  is  lost, 
while  in  the  latter  the  knee  remains  permanently  stiffened. 

Treatment. — If  the  fragments  are  widely  separated, 
and  if  loose-jointedness  is  manifested,  the  patient  is 
obliged  to  wear  a  jointed  support  at  first ;  subsequently, 
this  can  be  replaced  by  a  simple  knee-cap.  For  the  mus- 
cular atrophy  nothing  can  be  done.  The  usual  treatment 
of  ankylosis — by  exercise,  massage,  electricity,  baths,  etc. — 
is  to  be  employed. 

Insurance  allowance,  usually  from  33^^  to  50^. 

It  is  very  questionable  whether  we  are  justified  in 
regarding  the  atrophy  of  the  quadriceps  as  always  of 
reflex  origin,  connected  with  morbid  processes  in  the 
spinal  cord,  since  in  most  cases  the  condition  can  be  fully 
explained  on  mechanical  grounds  alone.  The  fact  that 
the  points  of  attachment  of  the  quadriceps,  more  particu- 
larly of  the  rectus,  are  approximated  by  the  upward  dis- 
placement of  the  upper  fragment,  is  a  sufficient  cause  for 
the  atrophy.  Secondarily,  it  is  true,  the  atrophy  also  in- 
volves the  flexors,  the  muscles  of  the  buttocks,  leg,  and 
foot,  and  in  certain  cases  it  may  be  proj)er  to  attribute  it 
to  disorder  of  the  central  nervous  system.  As  a  rule, 
however,  no  such  explanation  is  necessary.  The  atrophy 
persists  for  many  years.  If  the  lateral  ligaments  remain 
intact,  the  muscles  sometimes  recover  to  a  large  extent 
even  though  the  fragments  are  widely  separated.  In 
other  cases  the  atrophy  gradually  increases. 

Case  of  indirect  transverse  fracture  of  the  left  patella,  followed  by  severe 
functional  disability.    (Fig.  71,  p.  405.) 

A  workman,  twenty-six  years  of  age,  when  carrying  a  carpenter's 
horse,  on  January  28,  1893,  slipped  and  fell  over  backward.  He  was 
treated  in  the  hospital  and  subsequently  in  the  dispensary.  When  I 
examined  him  on  April  22,  1893,  I  found  the  fragments  separated  to 
the  degree  shown  in  the  accompanying  illustration.  The  patient  was 
unable  to  lift  the  leg  except  with  much  exertion,  and  it  dragged  in 
walking.     Extension  and  flexion  of  the  knee-joint  were  almost  sus- 


1-  ig.  72. 


408  DISEASES  CAUSED  BY  ACCIDENTS. 

penclecl,  ami  the  wliole  liml>  was  atrophied.  The  circumference  of 
the  middle  of  the  tlii^h  was  diminished  6  cm.,  that  of  the  knee  5 
cm.,  and  that  of  the  calf  nearly  '2  cm.  The  patient  was  obliged  to 
wear  a  supporting  apparatus.  At  the  time  of  another  examination,  in 
November,  1896,  I  found  the  atrophy  still  more  ad\ance(i;  the  circum- 
ference at  the  level  of  the  iliofemoral  crease  was  diminished  8  cm.,  that 
of  the  middle  of  the  thigh  9  cm.,  and  the  knee  2  cm. 

Insurance  allowance,  (JU^.  No  improvement  up  to  the  present 
time. 

Case  of  indirect  fmctnre  nf  the  patella  caused  by  viuscular  action,  on  the 
occasion  of  a  fall  from  a  netiffolding.    (Fig.  72,  p.  407.) 

A  Avorkman,  twenty-six  years  of  age,  sustained  a  fracture  of  the  pa- 
tella as  just  stated.  Some  improvement  has  gradually  taken  place  in 
the  course  of  time,  since  the  lateral  portions  of  the  extensor  aponeuro- 
sis remained  intact.  The  interval  between  the  fragments  admitted 
the  full  width  of  the  liand.  The  atrophy  was  extreme  at  tirst,  the 
circumference  of  the  thigh  being  diminished  6^  cm.  At  the  pres- 
ent time  there  is  only  a  slight  difference  in  the  measurement  of  the 
two  sides.  The  patient  can  walk  very  well  and  can  do  light  work. 
Insurance  allowance,  50  ^  ;  later,  33  J  % . 

Case  of  direct  fracture  of  the  right  patella.  (Fig.  73,  p.  409.) 
A  mason,  thirty-eight  yeare  of  age,  fell  from  a  scaffolding  on  April 
13,  1897,  striking  on  the  right  knee  and  left  hand.  An  extension  ap- 
paratus was  applied  for  seven  weeks  in  the  hospital.  Tlie  patient  \\as 
subsequently  treated  in  my  clinic  from  July  14,  1897,  until  June  3:3, 
1898.  He  was  a  tall,  stout  man  ;  the  right  knee  was  completely  anky- 
losed  and  greatly  swollen  ;  it  was  fixed  at  an  angle  of  175  degrees, 
and  the  muscles  were  greatly  atrophied.  The  accompanying  skiagraph 
was  taken  four  week  after  the  first  examination.  The  lower  fragment 
was  firmly  fixed  between  the  tibia  and  the  femur.  When  discharged, 
the  knee  could  be  actively  flexed  only  to  an  angle  of  120  degrees; 
there  has  been  no  subsequent  improvement.  The  patient  has  mean- 
while developed  a  severe  case  of  tuberculosis. 

Case  of  direct  comminuted  fracture  of  the  right  patellar.  (Fig.  74, 
p.  410. ) 

The  knee  was  put  up  in  plaster  for  fourteen  and  a  half  weeks,  and 
the  patient  was  then  allowed  to  walk.  He  was  treated  in  my  clinic 
from  January  13,  1898,  until  March  19,  1898.  The  knee-joint  was 
swollen,  and  the  outline  of  the  patella  was  indistinct.  On  palpation 
tlie  patella  felt  somewhat  uneven.  Flexion  was  limited  to  an  angle  of 
125  degrees. 

At  the  time  of  his  discharge  flexion  was  increased  to  an  angle  of 
85  degrees,  and  there  was  no  difficulty  in  walking.  The  shape  and 
displacement  of  the  patella  are  ch-ariy  shown  in  the  skiagraph,  in 
which  the  line  of  fracture  can  also  be  eiisily  traced. 


Fig.  73. 


Fig.  74. 


TUBERCULOSIS  OF  THE  KNEE.  411 


Fractures  of  the  Knee-joint. 

(Fourteen  Cases  Involving  the  Femur  or  Tibia. ) 

The  lesion  may  consist  of  a  fracture  of  the  articular 
extremity  of  the  femur,  of  the  tibia,  or  of  both.  The 
knee  is  usually  left  weak,  ankylosed,  and  fixed  in  exten- 
sion or  flexion.  The  nuiscles  connected  with  the  joint 
undergo  atrophy. 

The  disadvantage  of  a  stiff  knee  to  a  workman  is 
usually  greater  when  the  knee  is  extended  than  when 
moderately  flexed — say,  at  an  angle  of  from  145  to  155 
degrees.  Lameness  in  the  latter  case  can  be  obviated  by 
wearing  a  raised  shoe,  and  the  patient  may  then  be  able  to 
mount  and  ascend  a  ladder  with  a  load  on  his  shoulder. 
He  is  also  better  able  to  put  on  and  take  oft*  his  trousers, 
to  board  horse-cars,  omnibusses,  etc.,  than  if  the  leg  were 
fixed  in  extension. 

The  prognosis  is  more  favorable  as  to  functional  ])Ower 
if  only  partial  ankylosis  exists,  or  if  the  fixation  is  due  to 
a  contracture  which  still  permits  of  some  movement  of 
the  joint.  When  the  stiftiiess  is  due  to  resection,  the 
insurance  allowance  is  usually  rated  higher  than  other- 
wise, because  of  the  additional  shortness  of  the  limb. 

Insurance  allowance,  when  the  knee  is  fully  extended, 
from  50^  to  60^  ;  Avhen  flexed  at  an  angle  of  about 
160  degrees,  from  25^  to  33^^  ;  wdien  greatly  flexed, 
necessitating  the  wearing  of  a  wooden  leg,  from  70  ^  to 
80^.  The  rate  is  considerably  affected  by  the  ability  or 
inability  of  the  patient  to  kneel. 

Tuberculosis  of  the  Knee==joint. 

Traumatism,  when  it  affects  a  tuberculous  individual, 
not  infrequently  acts  as  the  exciting  cause  of  tubercular 
inflammation  of  the  knee-joint.  The  injury  may  be 
slight  or  serious,  such  as  a  contusion,  a  sprain,  a  frac- 
ture, etc.     It   may  be   possible   to   prevent  the   local  de- 


412  DISEASES   CAUSED  BY  ACCIDENTS. 

velopraent  of  the  disease  if  the  patient  is  phiced  under 
treatment  immediately  after  the  accident,  but  if  the  syno- 
vitis once  gains  headway,  it  leads  to  the  development  of 
an  obstinate  and  destructive  inflammatory  process,  which 
may  progress  indefinitely,  doing  irreparable  damage  to 
the  joint.  Resection  is  often  indicated.  Sometimes  the 
pus  works  its  way  to  the  surface  and  the  inflammatory 
process  comes  to  an  end,  leaving  the  joint  stiff  and 
deformed  and  marred  by  scars. 

Symptoms. — Insidious  onset  and  development  of  the 
inflannnation  ;  swelling  of  the  knee,  marked  by  tension 
and  absence  of  effusion  ;  gradual  change  of  shape  of  the 
part ;  fever,  atrophy,  etc. 

Insurance  allowance  during  the  acute  or  subacute  stage, 
100^. 

Chronic  Traumatic  Inflammation  of  the  Knee=joint ;  Arthritis 
Deformans  ;  Osteo=arthritis  of  the  Knee. 

When  the  knee-joint  is  severely  contused  or  crushed  it 
may  become  the  seat  of  a  chronic  inflammation  (arthritis 
deformans),  especially  if  the  affected  individual  is  subject 
to  frequent  attacks  of  rheumatism.  The  functional  power 
of  the  joint  is  considerably  diminished,  and  the  patient  is 
frequently  obliged  to  stop  work  on  account  of  pain  in  the 
joint,  especially  when  the  weatlier  is  changeable.  The 
knee-joint  becomes  greatly  enlarged  and  deformed  ;  it  is 
completely  or  partly  ankylosed,  and,  as  a  rule,  is  flexed 
and  partly  dislocated. 

It  may  be  many  years  before  the  patient  is  completely 
incapacitated  for  self-support. 

Insurance  allowance,  according  to  the  severity  of  the 
case,  33  J  ^  or  more. 

Case  of  traumatic  arthritic  deformans  iiivolriii;/  the  knee. 

A  woman  forty-five  years  of  age  sustained  in  her  twentietli  year, 
a  fracture  of  tlie  left  tiliia  just  below  the  knee.  She  was  under  treat- 
ment for  eight  months,  afterward  resuming  work  in  a  factory.  In  con- 
sequence of  repeated  contusions  received  during  subsequent  years  the 
left  knee  gradually  became  more  and  more  swollen  and  misshapen. 


INJURIES  OF  THE  LEG.  413 

When  I  examined  her,  on  March  3,  1899,  I  found  the  knee  greatly 
deformed;  it  was  much  enlarged,  flexed,  and  in  a  position  of  varus  ; 
it  was  almost  completely  aid^ylosed  and  was  very  painful.  Tlie 
muscles  were  atrophied  and  tlie  part  was  cold.  The  patient  com- 
plained of  severe  pain.     Insurance  allowance,  50%. 


5.  INJURIES  AND  TRAUMATIC   DISEASES  OF  THE  LEG. 

Injuries  Due  to  Contusion. 

(156  Cases,  Including  Wounds. ) 

Slight  contusions  of  tlie  tibia  are  usually  followed  by 
rapid  and  perfect  recovery.  Even  in  case  of  extensive 
blood  extravasations,  which,  on  account  of  the  vascularity 
of  the  part,  are  frequent,  the  injury,  if  properly  treated, 
does  not  lead  to  subsequent  functional  disability. 

The  periosteitis  caused  by  contusions  seldom  gives  rise 
to  much,  if  to  any,  pain,  and  does  not,  as  a  rule,  prevent 
the  patient  from  working.  If,  on  the  other  hand,  the 
periosteitis  appears  in  connection  with  a  contused  wound, 
which  subsequently  becomes  infected,  the  consequences 
may  be  very  serious. 

A  workman,  thirty-five  years  of  age,  grazed  his  right  shin  in  using 
a  heavy  hammer,  causing  a  slight  abrasion  of  the  skin.  A  suppurative 
periosteitis  developed  ;  the  wound  continued  to  disc^harge  for  a 
year,  when  it  finally  healed,  leaving  a  broad,  shining  scar,  adherent 
to  the  bone  and  exceedingly  sensitive.  The  slightest  touch,  even  of 
the  surrounding  skin,  would  cause  violent  contractions,  and  very 
Intense  and  long-continued  tetanic  spasms  could  be  produced  by 
testing  the  patellar  reflex.  The  knee  was  weak  and  was  fixed  in 
flexion;  the  patient  walked  with  difficulty,  leaning  on  two  canes. 
Insurance  allowance,  100  % . 

Contusions  of   the  Calf. 

These  usually  run  a  favorable  course,  absorption  of 
the  hemorrhagic  extravasation  being  quickly  promoted  by 
appropriate  treatment — rest,  compresses,  etc.  The  same 
may  be  said  of  contusions  affecting  the  tendo  Achillis. 
The  prognosis  becomes  more  serious,  however,  when  the 
leg  is  crushed  under  heavy  ol))ects,  such  as  beams,  stone 
slabs,  iron  rails,  etc.,  or  when  the  individual  is  caught  in 


414  DISEASES  CAUSED  BY  ACCIDENTS. 

a  cavino:-in  or  is  run  over.  Such  accidents  are  likely  to 
cause  extensive  wounds,  simple  or  compound  fractures, 
ruptures  of  muscles  and  teudons,  and  lacerations  of  the 
fasciae.  When  fractures  are  jiresent,  the  usefulness  of  the 
part  is  usually  permanently  impaired  ;  otherwise,  if  ]>roper- 
ly  treated,  no  permanent  functional  disability  need  follow. 
The  course  of  treatment,  however,  is  apt  to  l)e  protracted. 
Although  in  simple  cases  of  crushing  of  the  leg  a 
favorable  result  may  usually  be  expected,  the  outlook 
becomes  very  different  when  the  leg  is  the  seat  of  some 
morbid  process.  Quite  ajiart  from  the  disproportionate 
effects  of  slight  injuries  in  the  presence  of  a  constitu- 
tional disease,  such  as  locomotor  ataxia, — when  simple 
contusions,  for  instance,  may  cause  a  fracture, — when 
the  leg  is  affected  by  varicose  veins  or  cicatrized  vari- 
cose ulcers  it  needs  only  the  irritation  consequent  upon 
a  contusion  or  slight  abrasion  to  excite  an  inflamma- 
tion leading  to  the  development  of  new  ulcers  or  to  the 
reopening  of  old  ones.  The  ulcers  may  become  as  large 
as  the  palm  of  the  hand,  and  unless  the  process  is  brought 
to  a  termination,  may  be  followed  in  the  course  of  time 
by  swelling  and  inflammation  of  the  whole  leg  (elephan- 
tiasis cruris  traumatica).  When  the  inflammation  is  severe, 
the  patient  should  remain  in  bed,  with  the  leg  elevated, 
and  the  wound  should  be  kept  scrupulously  clean.  A 
2fc  to  4^  solution  of  acetate  of  aluminium  is  sometimes 
remarkably  efficacious.  If  there  is  no  marked  inflamma- 
tory reaction  in  the  surrounding  tissue,  and  it  is  only  a 
question  of  cicatrization  of  the  ulcers,  it  is  advisable  in 
many  cases  to  use  a  prepared  zinc  bandage,  which  enables 
the  patient  to  continue  work  and  may  not  need  renewal 
for  a  week  or  two.  These  zinc  bandages  are  certainly  of 
great  service  to  working-men  suffering  from  varicose 
ulcers.  If  such  a  man  were  to  be  sent  to  the  hospital 
every  time  a  healed  ulcer  should  break  down  afresh,  he 
and  his  family  would  be  reduced  to  starvation.  The 
bandages  are  highly  valued  by  both  doctors  and  patients ; 


WOUXBS  OF  THE  LEG.  415 

many  workmen  treat  them^ielves,  indeed,  on  the  same 
principle,  although  imperfectly,  by  nsing  ointments  and 
bandages,  and  perform  the  same  tasks,  year  in,  year  ont,  as 
their  healthy  comrades,  although  the  ulcers  remain  open 
and  suppurating.  We  should,  however,  insist  on  seeing  a 
patient  at  least  once  or  twice  a  week,  changing  the  bandage 
as  soon  as  it  is  soiled  through  by  secretion.  The  patient 
must  be  impressed  with  the  necessity  of  going  at  once  to 
the  physician  when  this  occurs.  As  the  traumatism 
is  usually  responsible,  at  the  most,  for  no  more  than  a  new 
outbreak  of  the  old  trouble,  20^  is  ordinarily  a  sufficient 
insurance  allowance  when  the  patient  is  able  to  work,  with 
due  consideration  for  the  likelihood  of  recurrences. 

In  respect  to  wounds  of  the  leg,  incised  wounds  are 
among  the  most  important.  They  are  seen  in  carpenters 
and  others  whose  work  exposes  them  to  accidents  with 
hatchets  or  axes,  or  in  farm-hands  who  handle  scythes. 
They  heal,  as  a  rule,  without  difficulty,  and  the  scars  give 
no  trouble,  unless  by  reason  of  deep  attachments.  The 
results  are,  of  course,  serious  when  tendons,  vessels,  or 
nerves  are  involved  in  the  cut.  Infected  woiuids  of  the 
leg,  Avhich  in  healing  form  cicatricial  adhesions  with  the 
bone,  are  characterized  by  extreme  sensitiveness,  which 
in  some  cases  rather  increases  than  diminishes  after  the 
scar  is  fully  formed. 

The  wounds  of  the  back  of  the  leg,  with  which  we  have 
to  deal,  are  usually  caused  by  a  scythe,  and  involve  either 
the  calf  or  the  tendo  Achillis.  Wounds  of  the  calf 
usually  heal  without  further  difficulty.  Healing,  when 
the  tendo  Achillis  is  severed,  is  a  slower  process,  but 
is  likely  to  terminate  favorably.  Unless  primary  union 
takes  place,  a  cicatricial  contracture  of  the  tendon  is 
likely  to  be  developed,  causing  flexion  of  the  knee  and 
talipes  equinus.  The  action  of  the  ankle-joint  is  restricted 
and  cramps  of  the  muscles  of  the  calf  are  frequently 
observed.  These  unfavorable  results  can  be  entirely 
overcome,  however,  by  massage,  baths,  and  electricity. 


416  DISEASES  CAUSED  BY  ACCIDENTS. 

Cane  of  division  of  the  tendo  Acliillis,  followed  by  eietdrieird  eontnietion 
and  relaiively  slif/Jit  functional  dis(d/iliti/. 

A  workman,  forty-five  years  of  age,  cut  the  back  of  his  leg  -witli  a 
bread-knife,  completely  severing  the  tendo  Achillis,  on  June  2fi,  1897. 
He  was  treated  in  the  hospital,  Avhere  the  tendon  was  sutured ;  the 
wound,  liowever,  healed  ^ery  slowly.  It  was  still  open  when  the 
patient  came  under  my  care,  on  October  23,  1897.  After  healing  it 
left  a  firmly  adherent  scar,  extending  to  the  internal  malleolus.  The 
knee  was  slightly  flexed,  and  there  was  a  slight  tendency  toward 
talipes  equinus.  The  muscles  of  the  calf  were  atrophied  and  were  sub- 
ject to  cramps.  Tlie  mobility  of  the  ankle  and  toes  was  some^vhat 
restricted,  and  there  was  a  feeling  of  numbness  in  the  heel  and  the  sole 
of  the  foot.  The  patient  made  considerable  improvement.  Insurance 
allowance,  20%. 

Burns  and  Scalds  of  the  Leg. 

In  severe  cases  healing  is  very  protracted,  and  wlien  it 
finally  takes  place  patients  find  it  very  difficult  to  walk  or 
to  bear  their  weigiit  on  the  aifected  leg  for  a  long  time. 
At  first  they  are  obliged  to  use  crutches,  and  always  com- 
plain of  a  feeling  of  great  insecurity  in  the  leg,  which  is 
only  slowly  and  gradually  overcome.  The  scars  in  some 
cases  present  zones  of  extreme  hyperesthesia,  while  in 
other  cases  analgesia  is  manifested. 

Subcutaneous  ruptures  of  the  muscles  of  the  calf  occur 
in  the  lower  part  of  their  course,  usually  as  the  result  of 
reflex  contraction  of  the  muscles,  following  a  fall  or  a 
leap,  landing  on  the  feet.  Occasionally,  only  the  posterior 
extremity  of  the  os  calcis  is  torn  oif ;  less  frequently,  the 
muscles  give  way  where  they  merge  into  the  tendo 
Achillis,  and  in  rare  cases  the  extremity  of  the  os  calcis  is 
torn  off  and  the  tendo  Achillis  is  ruptured  at  the  same 
time.  The  subject  will  be  referred  to  again  under  Frac- 
tures of  the  Os  Calcis. 

Case  of  scald  of  both  legs  and  feet  followed  hij  very  protracted  recovery. 

A  painter,  thirty-three  years  of  age,  fell  from  a  scaffolding  into  a 
boiler  full  of  boiling  water  on  June  4,  1889,  sustaining  the  foregoing 
injuries.  He  was  treated  in  the  hospital  until  September  20,  1889.  I 
examined  him  at  his  home  on  Septemlier  23,  1889.  He  was  utterly 
unable  to  walk,  or  even  to  stand.  About  three  months  later  he  began 
to  walk  with  two  crutches.  Both  ankles  were  encircled  by  smooth, 
sujierficial  scars;   both  legs,    more  particularly  the  right,    were   like- 


FRACTURES  OF  THE  LEG.  417 

wise  badly  scarred.  The  muscles  were  slightly  atrophied  and  the 
temperature  of  the  skin  was  lowered.  The  scars  were  extremely 
sensiti\e  and  the  legs  appeared  strikingly  weak.  The  jmtient  was 
discharged  on  April  21,  1891,  with  an  insurance  allowance  of  33J  % . 

On  October  14,  1^96,  he  appeared  for  examination,  complaining  of 
feeling  worse.  There  were  fibrillary  and  clonic  contractions  of  the 
muscles  of  both  legs;  the  ])atellar  reflexes  were  extremely  exaggerated 
and  ankle-clonus  could  be  obtained  on  both  sides.  The  patient  walked 
very  cautiously  and  slowly,  and  swayed  when  his  eyes  were  closed. 
There  was  numbness  of  the  soles  of  l)oth  feet.  The  muscles  were 
not  atrophied.     Pulse,  100;  irregular. 

The  insurance  allowance  was  rai.sed  to  50  % . 

Fractures  of  the  Leg. 

(190  Cases.) 

Fractures  of  the  Upper  End  of  the  Tibia. — The 

typical  fracture  in  this  situation  is  due  to  compression  of 
the  bone  in  its  long  axis,  as  a  result  of  such  accidents  as 
falling  squarely  on  the  feet  from  a  height,  jumping  from 
a  bicycle,  etc. 

AVhen  the  injury  is  slight,  the  tibia  is  only  fissured  ;  in 
severe  cases  the  upper  end  of  the  bone  is  driven  more  or 
less  into  the  shaft,  or  the  U23per  articular  surface  is  flat- 
tened and  broadened,  or  the  effect  of  the  violence  may  be 
still  differently  manifested — by  a  concave  depression  in 
the  head  of  the  tibia  corresponding  to  the  convexity  of 
one  of  the  condyles  of  the  femur  which  was  forced  into  it. 
The  fibula  is  always  involved  in  cases  of  severe  com- 
pression. 

As  these  fractures  involve  the  joint,  they  may  be 
further  complicated  by  injuries  of  the  semilunar  fibro- 
cartilages,  which  are  sometimes  thrown  out  of  position, 
and  perhaps  also  by  a  fracture  of  the  spinous  process  of 
the  tibia.  Symptoms  of  inflammation  of  the  knee-joint 
are  always  ]n*eseut  at  first. 

Symptoms  subsequent  to  consolidation  :  The  leg  is 
shortened  ;  the  knee  is  thickened  and  enlarged  ;  the  head 
of  the  til)ia  presents  an  increased  circumference  and  a  de- 
formity which  remains  after  the  swelling  subsides ;  the 
joint  is  in  a  position  of  subluxation,  with  varus  or  per- 
27 


418  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  33. 

Case  of  Compression=fracture  of  the  Left  Tibia  and  Head 
of  the  Fibula,  Due  to  Falling  from  a  Scaffolding,  Landing  on 
the  Feet,     (Sec  Fig.  75,  p.  419.) 

A  mason,  thirty-eight  years  of  age,  sustained  the  foregoing  injuries 
on  June  11,  1896.  He  was  treated  in  the  hospital  for  eleven  weeks, 
and  su))sequently  in  an  "institute  for  mechanical  treatment"  for 
thirteen  weeks.  He  began  to  attend  my  clinic  on  February  28,  1898. 
The  accompanying  ilhistratif)n  was  made  shortly  l)efore  his  discharge. 
The  left  leg  is  distinctly  shortened,  the  knee-joint  is  thickened  and 
slightly  rotated  outward,  there  is  a  slight  degree  of  genu  \arum,  the 
leg  is  somewhat  swollen,  and  the  thigh  is  atroi^hied.  The  skiagraph 
(Fig.  75,  p.  419)  shows  the  fracture  very  clearly. 

haps  valgus ;  the  whole  leg  shows  signs  of  atrophy  ;  the 
knee-joint  is  partly  or  completely  ankylosed  ;  if  move- 
ment is  permitted,  it  is  accom])anied  by  crepitation. 
Farther  symptoms  are  lameness,  pain,  secondary  displace- 
ments of  the  hip  and  ankle,  and,  frequently,  an  inability 
to  kneel. 

Treatment. — The  knee  is  to  be  mobilized  by  exercises 
and  massage  ;  a  boot  with  raised  sole  is  sometimes  to  be 
recommended.  A  very  long  course  of  treatment  is  re- 
quired in  unfavorable  cases,  the  symptoms  previously 
named  being  very  persistent.  Insurance  allowance,  from 
25^  to  50^. 

Fractures  of  the  Leg  Near  the  Knee. — The  con.se- 
quences  of  these  fractures  are  manifested  ])oth  by  dis- 
placement and  loss  of  functional  power  of  the  knee-joint. 
We  find  the  leg  shortened  and  the  knee-joint  thickened, 
as  is  also  the  head  of  the  fibula,  if  this  was  involved  in 
the  fracture.  There  is  genu  valgum  or  varum,  the 
muscles  are  atrophied,  the  mobility  of  the  knee-joint 
is  restricted,  and  there  is  difficulty  in  walking. 

Corresponding  secondary  disjilacements  are  manifested 
in  both  the  hip-joint  and  the  ankle-joint. 

Separation  of  the  tubercle  of  the  tibia  caused  by  mus- 
cular action  is  never  more  than  a  ])artial  separation,  and 
is  rarely  met  with  in  adults.     The  lesion  is  usually  of  a 


Tab.  33. 


( 


Fi'i  1  j_. 


Lirh.  Anst  F.  ReLchlwld.,  Mundu 


Fig.  75. 


420  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  34. 

Case  of  Genu  Valgum  Following  a  Fracture  of  the  Leg 
Just  Below  the  Knee.     (See  Fig.  76,  p.  4-21.) 

A  workman,  twenty-seven  years  of  age,  ^^as  injured  as  just  stated 
on  February  4,  1898,  by  a  pail  falling  against  tbe  outer  side  of  his  left 
leg.  The  patient  was  treated  at  home  in  the  country;  splints  were 
applied  for  one  day,  a  plaster  cast  being  substituted  on  the  following 
day.  Eight  weeks  after  the  accident  he  began  to  walk  with  the  aid  of 
a  crutch  and  a  cane.  He  was  treated  in  my  hospital  from  May  15, 
until  August  18,  1898.  The  form  of  the  fi'acture  is  shown  in  the 
accompanying  skiagraph.  In  the  colored  plate  we  can  see  the  edema 
and  atrophy  of  the  leg,  the  atrophy  of  the  thigh,  the  venous  conges- 
tion of  the  leg  and  foot,  and  the  genu  valgum. 

Insurance  allowance,  20%. 

The  functional  power  of  the  knee  was  completely  restored  by  the 
treatment.  The  skiagraph  ( Fig.  76 )  is  to  be  regarded  as  a  mirror- 
picture. 


trivial  nature.  As  a  result  the  tubercle  is  found  thick- 
ened, the  ligauientum  patellse  is  somewhat  loosened,  and 
the  quadriceps  shows  signs  of  slight  atrophy. 

Fractures  of  the  head  of  the  fibula  have  already  been 
referred  to  ;  they  are  directly  produced  by  kicks  or  falls, 
or  by  the  trauniatisiu  incidental  to  a  caving-in,  or  occur 
indirectly  in  consequence  of  falling  from  a  height  and 
landing  on  the  feet,  in  connection  \vith  compression-frac- 
tures of  the  tibia.  Sometimes  the  lesion  takes  the  form 
of  a  comminuted  fracture.  Occasionally  the  head  of  the 
fibula  is  torn  off  by  the  action  of  the  biceps.  Healing  is 
characterized  by  a  well-marked  growth  of  callus,  by 
which  the  bone  is  left  more  or  less  distinctly  thickened  ; 
the  biceps  undergoes  atrophy,  and  occasionally  is  found 
extremely  tense  or  definitely  contracted,  causing  outward 
rotation  of  the  leg  and  outward  disphicement  of  the  head 
of  the  fibula.  Severe  cases  may  be  accompanied  by  \mv- 
alysis  of  the  peroneal  nerve,  due  to  its  direct  injury. 

The  knee-joint  is  not  affected  by  isolated  fractures  of 
the  head  of  the  fibula,  except  in  the  unusual  instances  in 
which  it  is  in  communication  with  the  superior  tibiofibular 


Tab.  J4. 


Fiij 
Lull.  An.st  H  Heidihold.  Huiui. 


Fig.  76. 


422  DISEASES   CAUSED  BY  ACCIDENTS. 


PLATE  35. 

Atrophy  of  the  Left  Lower  Extremity  After  a  Fracture  of 
the  Tibia,  Involving  the  Bony  Ridge  Anterior  to  the  inferior 
Tibiofibular  Articulation,  and  Contusion  of  the  Leg. 

The  subject  of  the  accompany in<>;  ilhistr-ation  was  a  mason,  thirty- 
eiffht  years  of  age,  who  was  injured  on  May  1,  1897,  by  a  beam  falling 
against  his  left  leg.  ITe  was  at  first  treated  at  home,  subsequently 
entering  a  hospital,  where  he  remained  for  three  weeks.  He  was  a 
patient  in  my  hospital  from  Fe))ruary  'js,  until  June  14,  1H98,  when 
he  was  discharged  with  an  insurance  allowance  of  50/^.  The  atrophy 
in  this  case,  which  in\(>lved  the  whole  extremity,  was  particularly  re- 
sistant to  treatment;  the  temperature  of  the  foot,  including  the  sole, 
was  reduced.  The  illustration  shows  the  general  atrophy  of  the  limb 
very  well;  the  affected  muscles  included  the  gluteus  medius,  sartorius, 
quadriceps  extensor,  tibialis  anticus,  gastrocnemius,  aljductor  pollicis, 
etc.  The  muscles  of  the  foot  are  evidently  involved  as  well ;  even  the 
left  heel  is  smaller  than  the  right,  and  the  impression  (Fig.  77)  of  the 
sole  indicates  a  similar  condition  of  the  muscles  in  that  situation. 


joint,  when   it  is  likely  to  share  the  inflammation  of  the 
latter. 

Dislocation  of  the  head  of  tlic  filnila  is  very  rarely 
seen  as  a  separate  lesion  ;  it  usually  occurs  as  a  secondary 
effect  in  cases  of  fracture  of  the  tibia  accom])anied  by 
marked  displacement  of  the  fra,s»;nients.  Fractures  of  the 
head  of  the  fibula  are  regularly  conij)licated  by  partial 
dislocation,  due  to  the  action  of  the  biceps. 

In  one  case  of  forward  dislocation  of  the  head  of  the  left  fibula 
which  came  under  my  observation  I  found  the  knee  flexed  and  the 
tendon  of  the  bicejjs  very  prominent,  \\hile  the  muscle  itself  was 
tensely  contracted.  The  jieroneal  ner\i'  \\as  very  sensitive,  and  move- 
ment of  the  knee  was  rendered  difficult;  there  was  talipes  valgus,  and, 
in  addition,  .slight  atrophy  of  the  muscles  of  the  thigh. 

The  abnormal  position  of  the  head  of  the  fibula  in 
cases  of  dislocation  induces  a  secondary  displacement  of 
the  external  malleolus  and  the  foot,  frequently  resembling 
the  displacement  due  to  fracture  of  the  malleolus.  This 
secondary  cflFect  on  the  inferior  tibiofibular  joint  is  only 
slightly  marked,  if  at  all,  in  cases  of  displacement  follow- 
ing fracture  of  the  head  of  the  fibula. 


I'nh.Xl. 


424  DISEASES   CAUSED  BY  ACCIDENTS. 


PLATE  36. 

Case  of  Pseudo=arthrosis  of  the  Left  Leg  Following  a 
Compound  Fracture. 

A  roofer,  twenty-four  years  of  age,  fell  from  a  roof  on  July  16, 
1898,  sustainiiifr  a  compound  fracture  of  the  left  le^,  and,  in  addition, 
a  contusion  of  the  lumbar  ^  ertelna'  and  a  fracture  of  the  riJj.s.  He 
spent  five  months  in  bed  in  a  hospital,  and  when  discharged  at  the  end 
of  that  time,  tlie  fracture  still  remained  ununited.  Tlie  point  of  frac- 
ture presented  a  well-marked  angular  deformity.  He  entered  my  hos- 
pital on  January  (i,  1899.  At  the  time  the  accomi)anying  illustration 
was  made,  in  the  beginning  of  Febriiary,  1899,  there  A\as  already  some 
impro\'ement  in  respect  to  gait,  as  a  result  of  medicomechanical  treat- 
ment and  the  use  of  a  local  support.  The  picture  shows  tlie  scar,  the 
displacement,  shortening,  venous  congestion,  and  atrophy,  and,  in 
addition,  the  diminished  size  of  the  foot  and  the  talipes  varus.  The 
malposition  of  the  foot  is  also  evidenced  in  the  impressions  of  the  sole. 
( Fig.  78. )  The  temperature  of  the  whole  extremity  was  reduced, 
more  especially  below  the  point  of  fracture.  Considerable  improve- 
ment has  since  taken  place.  Figure  1  h  of  the  plate  shows  the  scar  of 
the  leg  more  in  detail.     Insurance  allowance,  when  discharged,  50%. 

Fractures  of  the  Leg  in  Its  Middle  Third  and 
Lower  Half. — These  fractures  are  usually  due  to  direct 
violence,  and  are  met  with  as  a  result  of  many  different 
accidents.  Wheels  in  passing  over  the  leg  may  break  it ; 
it  may  be  struck  by  heavy  falling  objects,  violently  com- 
pressed, or,  again,  may  be  fractured  by  a  fall  from  a 
height,  etc. 

All  varieties  of  the  lesion  are  seen,  from  a  simple  trans- 
verse to  the  most  extensive  comminuted  fracture. 

The  symptoms  subsequent  to  consolidation  are  as 
follows  : 

The  bone  is  thickened  at  the  point  of  fracture;  some- 
times the  leg,  from  the  knee  to  the  tips  of  the  toes,  is 
swollen  and  cyanosed  ;  it  is  shortened  and  the  fragments 
are  dis])laced  forward,  backward,  or  to  the  sides ;  the 
knee  and  pelvis  are  lower  on  the  affected  side  ;  the  muscles 
of  the  whole  extremity  are  atrophied  and  there  is  difficulty 
in  walking,  the  patient  being  obliged  to  use  crutches  or  a 
cane  for  a  time.  Compound  fractures  are  further  character- 
ized by  scars  and  cicatricial  adhesions. 


lab.  :i(>. 


.  Anst  K  ReichhvUl.  Minrhcri 


Fig.  79. 


426  DISEASES  CAUSED  BY  ACCIDENTS. 

Displacement  is  secondarily  manifested  in  the  knee- 
joint  and  ankle-joint  by  a  position  of  valgus  or  varus  or 
by  overextension.  Genu  reeurvatum  and  talipes  equinus 
or  talipes  calcaneus  are  not  often  seen.  Abnormalities  of 
position  are  dis})layed  in  the  foot  itself,  as  well  as  in  the 
ankle-joint  and  malleoli.  Restricted  mobility  of  both 
knee-joint  and  ankle-joint  is  a  frequent  symptom.  Pain 
is  complained  of  for  a  long  time,  especially  after  exertion 
or  when  the  weather  suddenly  changes. 

The  treatment  is  symj)tomatic.  If  the  leg  is  much 
shortened,  a  laced  siioe  with  a  raised  sole  should  be  worn  ; 
if  the  patient  is  unable  to  bear  his  weight  on  the  leg,  a  re- 
movable plaster  cast  should  be  tried.  These  removable 
casts  are  constantly  in  use  in  my  clinic,  and  render  valuable 
service  ;  they  are  very  light,  are  easily  put  on  and  removed, 
and  frequently  take  the  place  of  a  more  expensive  support. 
The  leg  and  whole  extremity  should  be  massaged  regu- 
larly ;  electricity  and  baths  are  also  beneficial. 

Insurance  allowance  from  20^,  to  50^,  or  more,  ac- 
cording to  the  functional  disability.  If  the  patient  has  to 
depend  on  a  cane  for  walking,  the  rate  can  not  well  be 
made  less  than  50^;.  In  some  cases  it  can  be  lowered 
by  supplying  the  patient  with  a  good  supporting  appa- 
ratus. 

Cam'  offmclHi-e  of  the  left  leg.      (Fig.  79,  p.  425. ) 

A  painter,  twenty-tliiee  years  of  age,  fell  from  a  scaffolding  on  May 
9,  189H,  breaking  his  right  leg.  He  was  treated  in  the  hospital  until 
June  10,  189i-<,  and  subsequently  attended  my  clinic  from  July  29, 
until  October  18,  1H98.  The  symptoms,  in  addition  to  swelling,  were 
marked  thickening  at  the  point  of  fracture,  shortening,  and  genu  val- 
gum. At  first  there  was  considerable  lameness,  but  at  the  time  of  the 
patient's  discharge  this  had  disappeared,  and  his  gait  was  excellent. 
The  skiagraph  shows  the  condition  of  the  bone  at  the  time  of  discharge 
from  treatment.  Insurance  allowance,  2.5%  until  March  10,  1899, 
when  it  was  entirely  discontinued,  the  patient  ha\ing  fully  recovered. 

Case  of  fracture  of  the  left  teg  due  to  a  fall  from  a  height,  in  which  the 
fibula  healed  very  sloroly.      ( Fig.  80,  p.  427. ) 

A  carpenter,  thirtv-five  vears  of  age.  fell  from  a  scaffolding  six  feet 
high  on  October  15,  1894,  breaking  the  left  leg  in  its  lower  half.  The 
leg  was  very  edematous  at  first,  and  was  shortened ;  the  knee  was  over- 


Fig.  SO. 


428 


DISEASES  CAUSED  BY  ACCIDENTS. 


extended.     In  addition,  the  fragments  of  the  fihnla  failed  to  unite  for 
nearly  a  year.     The  patient  was  under  treatment  until  December  21, 


Fig.  81. 


1895;  at  that  time  the  limb  was  in  a  much  more  normal  position. 
The  insurance  allowance  was  at  first  fixed  at  45  %  :  reduced,  after  com- 


Fig.  82. 


430  DISEASES  CAUSED  BY  ACCIDENTS. 

plete  consolidation  of  the  fibula,  to  20%,  at  which  rate  it  has  con- 
tinued. The  man  is  unable  to  work  at  his  trade,  and  has  become  a 
cab-driver. 

Case  of  compound  fracture  of  the  right  leg.  Sequels:  marked  back- 
ward displacement;  a  moderate  degree  of  genu  recurvatum;  .severe 
functional  disability.     ( Fig.  81,  p.  428,  and  Fig.  82,  p.  429. ) 

A  polisher,  sixty-three  years  of  age,  fell  from  a  scaffolding  about 
six  feet  high  on  January  21,  1889,  sustaining  a  compound,  comminuted 
fracture  of  the  right  leg.  The  lower  fragments  pierced  the  calf.  He 
was  treated  at  first  in  a  hospital;  subsequently  at  his  home,  until 
October  23,  1890.  The  wound  continued  to  suppurate  and  fragments 
of  bone  to  be  throAvn  off  for  a  long  time;  finally  healing  took  place, 
leaving  scars  which  were  adherent  to  the  J)one,  lioth  l>ehind,  over  the 
calf,  and  in  front,  over  the  tibia.  The  illustration  shows  the  shorten- 
ing, the  curvature  of  the  bone  Ijackward,  and  the  adherent  scar  over 
the  tibia;  also  the  forward  displacement  of  the  foot  at  the  ankle-joint. 
In  the  skiagraph  the  union  between  the  tibia  and  fibula  and  tlie  dis- 
placement of  the  bones  backward  are  distinctly  displa^'ed.  Insurance 
allowance,  100%.    The  patient  is  obliged  to  use  two  canes  in  walking. 

Fracture  of  the  leg  in  its  Imver-half  followed  by  marked  displacem.ent, 
genu  valgum.,  and  talipes  valgus. 

A  carpenter,  forty-four  years  of  age,  sustained  a  fracture  of  the  left 
leg  on  August  13,  1891,  caused  hy  its  being  caught  l)etween  two  iron 
beams.  He  was  treated  in  the  hospital,  where  the  leg  was  kept  in 
plaster  for  seven  weeks,  afterward  attending  my  clinic  from  November 
14,  1891,  until  January  21,  1892.  The  leg  was  much  shortened;  the 
lower  fragment,  together  with  the  foot,  \\as  displaced  out\vard  to  a 
striking  degree,  and  the  bones  at  the  point  of  fracture  \\ere  greatly 
thickened.  Genu  valgum  and  talipes  valgus  were  also  present.  The 
leg  was  atrophied.  Insurance  allowance,  20%.  The  man  is  able  to 
do  most  of  tlie  work  appertaining  to  his  trade. 

The  skiagraph  (Fig.  83,  p.  431)  illustrates  the  case  of  a  workman, 
thirty-four  years  of  age,  who  fell  out  of  a  second-story  window  on  July 
5,  1897,  sustaining  a  severe  comminuted  fracture  of  the  right  leg  and 
fracture  of  l)oth  ankles.  On  tlie  right  side  the  fracture  involved  the 
malleoli,  and  on  the  left,  the  malleoli  and  the  os  calcis.  The  manner 
in  which  union  took  place  in  the  fracture  of  the  leg  is  beautifully 
exhibited  in  the  skiagraph.  The  accomi)anying  picture  (Fig.  84,  p. 
432)  shows  the  bony  thickening  at  the  point  of  fracture.  The  patient 
remained  in  the  hosjjital  until  August  30,  1897,  his  course  of  treat- 
ment with  me  lasting  until  August  11,  1898.  When  discharged,  he 
was  granted  50%  insurance  allowance,  raised  to  75%  by  the  court, 
at  which  rate  it  has  continued. 

Case  of  pseudo-arthrosis  of  the  tibia  and  reunited  fracture  of  the  fihida. 
(Fig.  85,"  p.  433,  and  Fig.  86,  p.  435. ) 

A  ma,s()n,  thirty  ye£irs  of  age,  sustained,  among  other  injuries,  a 
fracture  of  tlie  leg  caused  by  a  blow  from  an  iron  girder,  on  October 
16,  1889.  He  was  treated  in  the  hospital  for  a  littk'  over  one  year, 
being  then  discharged  at  his  wife's  request.  A  plaster  cast  \vas  applied 
for  eight  weeks,  the  subsequent  treatment  consisting  of  baths  and 


Fiy.  «:;. 


432  DISEASES  CA USED  BY  A CCI DENTS. 

electricity.  Figure  85  shows  the  scar,  the  point  of  fracture,  the  de- 
formity, and  tlie  thickening  of  the  l)one;  also  the  atrophy  of  both  legs 
and  the  shortening  of  the  affected  one.  The  atrophy,  especially  of  the 
left  buttock,  is  very  noticeable  in  the  rear  view.  In  the  skiagraph 
(Fig.  86,  p.  435)  the  pseudo-artlirosis,  the  bony  thickening,  and  the 
backward   displacement  of   the  fragments  of   the   fil)ula  are   clearly 


Fig.  84. 

visible.  The  patient  wears  a  supporting  apparatus  and  walks  with  a 
cane.  Insurance  allowance,  100%,  partly  based  on  a  badly  healed 
fracture  of  the  radius.  There  lias  been  no  improvement  up  to  the 
present  time.  The  accompanying  illustrations  were  made  at  the 
beginning  of  1899. 


FRACTURES   OF  THE  LEG. 


433 


The  skiagraph  (Fig.  87,  p.  436)  illustrates  the  case  of  a  workman, 
twenty-one  years  of  age,  in  whom  the  tibia  was  broken  on  June  3, 


Fig.  85. 


1897,  by  a  blow  from  an  iron  column  ^vhich  struck  it  in  falling.    He  was 
treated  in  the  hospital  until  September  2,  1897,  and  subsequently  in  my 


434  DISEASES  CAUSED  BY  ACCIDENTS. 

clinic  until  January  14,  1898.  The  symptoms  were  shortening,  genu 
valgiini,  talipes  valgus,  swelling,  lameness,  and  atrophy.  At  the  time  of 
the  patient's  discharge  the  malposition  of  the  knee-joint  and  ankle-joint 
had  almost  disappeared,  the  swelling  had  largely  subsided,  and  the 
atrophy  was  only  slightly  marked.  The  skiagraph  was  taken  at  that 
time.  It  was  not  until  a  year  later  that  an  X-ray  examination 
showed  the  fracture  to  be  completely  healed.  The  man  is  uov\'  able  to 
do  any  kind  of  hard  work,  and  receives  no  insurance  allowance. 

Fractures  of  the  Shaft  of  the  Tibia. — These  frac- 
tures, involving  the  middle  of  the  l)one  or  its  lower  half, 
occur  under  the  same  conditions  as  the  fractures  of  both 
bones  of  the  leg  at  these  points.  The  symptoms,  too,  are 
very  similar ;  the  displacement,  however,  is  usually  much 
less  marked.  Displacement  of  the  fragments  of  the  tibia 
causes  a  secondary  malposition  of  the  lower  and  upper 
tibiofibular  joints,  which  is  likely  to  interfere  with  the 
action  of  the  ankle-joint. 

Insurance  allowance,  from  20^  to  ^S^fc,  or  more. 
If  the  patient  subsequently  regains  good  use  of  the  leg, 
and  it  is  only  slightly  shortened,  the  insurance  allowance 
is  altogether  discontinued. 

In  cases  of  fracture  of  the  fibula  alone,  the  displace- 
ment is  most  unfavorably  manifested  at  the  inferior  tibio- 
fibular joint ;  talipes  varus  is  quite  a  frequent  sequel  of 
the  injury. 

Fractures  of  the  leg  sometimes  heal  in  bad  position  in 
spite  of  careful  treatment  in  the  best  hospitals.  I  have 
collected  a  consideral)le  number  of  sucli  cases,  of  many  of 
which  I  have  taken  photographs  or  skiagraphs  or  made 
plaster  models.  Since  poor  results  are  seen  even  in  hos- 
pitals in  which  the  most  improved  methods  and  appli- 
ances are  in  use,  we  certainly  have  no  riglit  to  jump  to  the 
conclusion  that  the  local  doctor  is  to  blame  when  such 
cases  are  brought  to  us  from  the  country.  We  must  re- 
member that  he  may  have  had  to  contend  with  the  con- 
ditions most  unfavorable  to  success. 

Fractures  of  the  lower  tliird  of  the  leg  are  quite  fre- 
quently caused  by  turning  the  ankle.     The  patients  are 


Fig.  87. 


Fig. 


438  DISEASES  CAUSED  BY  ACCIDENTS. 

often  found  to  be  sufferers  from  loeomotor  ataxia  the  pre- 
vious symptoms  of  wliicli  were  not  sufficiently  marked 
to  interfere  with  their  work.  We  are  usually  able  to 
observ^e  a  rapid  development  of  the  disease  subsequently 
to  the  injury. 

The  accident  also  occurs,  however,  in  individuals  who 
are  apparently  perfectly  healthy. 

Crt.se  of  fracture  of  the  right  (ibid  in  its  lower  third  caused  by  turning 
the  ankle  and  followed  bij  very  protracted  reeovcri/,  complicated  by  osteo- 
myelitis.    (Fig.  88,  p.  437.) 

A  mason,  forty-one  years  of  age,  slipped  and  fell  to  the  floor  in 
1888.  A  fracture  of  the  tibia  was  diagnosed,  and  the  patient  remained 
in  bed  for  nineteen  weeks.  Suppuration  took  pla<>e  one  year  later;  a 
fistula  formed  and  secpiestra  were  thrown  off.  The  patient  gradually 
became  able  to  walk,  but  could  do  very  little  work.  Suppura- 
tion continued  for  three  years.  Sub.secpiently  the  patient  frequently 
suffered  from  an  inflannnatory  condition  of  the  scar,  which  was  adher- 
ent to  the  bone.  No  insurance  allowance  was  granted,  i^  there  was 
no  trade-accident  involved. 

Figure  89,  page  439,  illustrates  a  case  of  reunited  supramalleolar 
fnicture  occurring  in  a  workman  forty-six  years  of  age  before  the  Acci- 
dent-insurance Law  was  passed.  He  remained  in  bed  for  four  weeks, 
and  two  weeks  later  began  to  do  light  work.  The  fracture  was  com- 
pletely consolidated  at  the  end  of  eight  weeks,  and  gave  no  further 
trouble. 

Case  of  reunited  fracture  of  the  leg  in  Us  lower  third,  with  bitckward 
and  lateral  displacement  of  the  fragments.      (Fig.  90,  p.  440.) 

The  lateral  displacement  is  clearly  shown  in  the  skiagraph.  As  a 
result  of  this  displacement,  the  malleoli  were  pushed  slightly  forward, 
especially  the  internal  malleolus;  the  change  of  position  in  the  external 
malleolus  was  somewhat  less  marked.  The  leg  was  somewhat  short- 
ened, genu  \algum  and  talipes  valgus  were  also  slightly  noticeable, 
and  the  moljility  of  both  joints  was  somewhat  restricted.  Insurance 
allowance,  from  May  1'2,  1899,  onward,  "25;^. 

Fractures  of  the  Leg  in  Its  Lower  Third  in  the 
Vicinity  of  the  Ankle-joint. — Tliese  fractures  have  a 
direct  etfcct  on  the  position  aud  functioual  power  of  the 
aid<lc-j()int. 

I,  Supramalleolar  Fractures. — Fractures  at  this  point 
are  usually  caused  by  tnrnino;  the  ankle,  by  falling  or 
jumping  from  a  height,  etc. 

The  .sipnptoins  are  talipes  valgus  or  varus  (compare  with 
fractures  of   the    malleoli) ;    shortening   of    the    leg  and 


Fig.  S9. 


Fig.  90. 


Fig.  91. 


Fig.  92 


442  DISEASES  CAUSED  BY  ACCIDENTS. 

thickening  of  its  lower  part ;  atrophy  of  the  whole 
extremity  ;  edema,  and  possibly  also  cyanosis,  at  first ; 
restricted  mobility  of  the  ankle-joint ;  and  difficnlty  in 
walking.  Supramalleolar  fractures  may  be  mistaken  for 
typical  fractures  of  the  malleoli. 

Figures  91  and  92,  page  441,  illustrate  a  case  of  supramalleolar 
fracture  of  the  right  leg,  occurring  in  a  carpenter  thirty-nine  years  of 
age,  who  fell  from  a  scaffolding,  and  in  falling  was  struck  on  the  outer 
right  malleolus  by  a  broken  l)oard.  The  line  of  fracture  of  the  tibia 
ran  obliquely  outward  from  a  point  about  two  lingers'-widths  above 
the  internal  malleolus.  The  fibula  was  broken  about  a  hand's-breatlth 
above  the  ankle-joint.  In  the  illustration  the  talipes  valgus,  the 
thickening  of  the  leg  above  the  ankle,  and  the  thickening  of  the 
tendo  Achillis  can  be  recognized;  also  the  atrophy  of  the  whole 
extremity. 

The  patient  was  at  first  treated  in  the  hospital,  l)eginning  a  course 
of  medicomechanical  treatment  on  December  18,  1897.  He  was  dis- 
charged on  August  17,  1898,  with  an  insurance  allowance  of  50%, 
reduced,  on  May  lr2,  1899,  to  20%.  At  the  time  of  his  discharge  the 
patient  walked  with  some  difficulty,  using  a  cane.  He  is  now  able  to 
do  all  the  regular  work  of  his  trade. 

Typical  case  of  supraindlltoldr  crcraion-fracturc  of  the  rigid  kg.  (Fig. 
93,  p.  44:5. ) 

A  mason,  forty-eight  years  of  age,  fell  to  the  ground  with  a  broken 
scaffolding  on  September  30,  1898.  The  line  of  fracture  and  the  typi- 
cal eversion  of  the  foot  are  shown  in  the  skiagraph.  The  patient  was 
under  treatment  until  February  17,  1899,  and  was  obliged  to  return 
for  subsequent  treatment  on  April  21,  1899.  The  ankle-joint  was 
almost  completely  ankylosed,  the  leg  was  shortened  and  atrophied, 
and  there  was  considerable  lameness. 

Insviranc*  allowance,  50%. 

Severe  ease  of  eoiti  mi  n  tiled  supra  malleolar  fracture  close  to  the  ankle- 
joint.     (Fig.  94,  ]).  414,  and  Fig.  95,  p.  415.) 

A  mason,  fifty -one  years  of  age,  fell  from  a  room-scaffolding  on  May 
27,  1898.  He  was  treated  at  first  in  tlie  hospital,  subsequently  coming 
under  my  care  from  August  11,  iHiH,  until  March  25,  1899,  when  he 
was  discharged  with  an  insurance  allowance  of  50%.  He  was  a  very 
tall  and  stout  man,  and  very  flat-footed.  The  whole  right  lower 
extremity  was  in  a  state  of  elephantiasis,  while  the  left  leg  was  also 
much  swollen.  The  skiagraph  ( Fig.  94 )  shows  the  splintered  bones 
and  the  disi)lacement  from  a  side  view.  The  ankle-joint  was  at  first 
completely  ankylosed;  its  mo])ilitv,  however,  was  restored  by  treat- 
ment.    Wlien  discharged,  the  j>atient  still  had  to  u.se  a  cane. 

2.  Separation  of  the  Epiphyses. — This  lesion,  occur- 
ring at  the  lower  extremity  of  the  bones  of  the  leg,  is 
met  with  only  in   young   people,  as   the   result  of  turning 


Fig.  93. 


Fig.  94. 


FRACTUEEH  OF  THE  TIBIA.  445 

the  ankle  in  sprino;ing  from  a  wagon  or  from  a  lieight,  or 
it  may  be  caused  by  direct  violence,  such  as  a  blow  from 
a  falling  object.  The  damage  is  usually  repaired  quickly 
and  perfectly  ;  in  one  case  coming  under  my  observation, 
in  addition  to  the  separation  of  the  epiphyses,  there  was  a 
fracture  of  the  fibula,  yet  the  patient,  a  boy  of  sixteen, 


Fig.  95. 

was  able  to  resume  work  in   precisely  four  weeks  from 
the  time  of  accident. 

Compression-fractures  of  the  Lower  End  of  the 
Tibia. — The  cause  is  the  same  as  of  similar  fractures  of 
th(;  upper  end  of  the  bone.  The  lesion  may  occur  in  con- 
nection with  a  compression-fracture  of  the  os  calcis  or  of  a 


446  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  37. 

Fig.  1. — Scars  Situated  in  the  Popliteal  Space,  on  the  Calf, 
and  around  the  Ankle=joint,  with  Venous  Congestion. 

The  subject  of  this  illustration,  a  workman,  sixty-two  years  of  age, 
suffered  from  a  cellulitis  of  the  right  ankle  and  leg,  following  an 
abrasion  of  the  skin.  The  scar  in  the  popliteal  space  became  greatly 
retracted,  and  would  break  open  every  time  the  knee  was  forcibly  ex- 
tended. In  consequence  of  this  constant  irritation  new  cicatricial 
tissue  continiied  to  form,  causing  flexion  of  the  knee.  The  patient 
was  in  my  care  from  INIarch  19,  until  June  IS,  IRJtrt,  when  he  was  dis- 
charged with  an  insurance  allowance  of  40^,  which  he  continues  to 
receive.  He  regained  complete  ability  to  extend  the  knee  without 
causing  injury  to  the  scar,  but  still  comjilains  of  pain  and  heaviness 
in  the  leg. 

Fig.  2. — A  workman,  thirty-five  years  of  age,  was  very  severely 
scalded  about  the  legs  by  boiling  water  on  November  26,  1894.  At 
the  same  time  the  boiler  containing  the  water  fell  upon  and  crushed 
his  legs,  the  left  leg  being  more  severely  injured.  The  wounds 
remained  open  and  suppurating  for  a  long  time.  Skin-grafting  was 
performed,  and  the  patient  was  under  treatment  for  nearly  two  years 
in  all.  Even  after  his  discharge  he  was  several  times  obliged  to  re- 
sume treatment. 

The  illustration  shows  the  extensive  scars  over  the  left  leg  and 
ankle.  The  ankle  is  quite  stiff  and  the  patient  walks  with  two  canes. 
Insurance  allowance,  90^.  During  the  past  year  his  gait  has  im- 
proved. 

vertebra,  and  it  is  usually  accompanied  by  fracture  of  the 
external  malleolus.  Suhsecjuent  stiffness  of  the  ankle-joint 
can  be  avoided  by  a  timely  diagnosis  and  appropriate 
prophylactic  measures.  The  after-symptoms  of  the  injury 
are  as  follows  : 

The  lower  part  of  the  leg  and  the  ankle  nnnain  thick- 
ened, perhaps  swollen  ;  the  leg  is  shortened  or  the  malleoli 
are  displaced  ;  there  may  be  talipes  valgus  or  talipes 
varus  ;  the  whole  extremity  shows  signs  of  atrophy,  the 
mobility  of  the  ankle-j(Mnt  is  restricted  and  the  gait  is 
affected.  In  one  case  of  compression-fracture  of  the  os 
calcis  and  the  lower  end  of  the  tibia,  accompanied  by  frac- 
ture of  the  external  malleolus  the  patient,  a  man  of  forty, 
and  a  liea\'y  drinker,  was  incapacitated  for  work  for  a 
period  of  nine  months. 


Tab.:)  7. 


\ 


Fiff.l. 


.f/> 


/V/.,^. 


/.it/i.  A/IS/  /■'  Hcxcliltolil .  Miuirliiri 


PSEUD0-ARTHR0SI8  OF  THE  LEG.  447 


Pseudo=arthrosis  of  the   Leg. 

A  false  joint  may  develop  after  fracture  of  either  one 
or  both  bones  of  the  leg.  When  the  tibia  is  involved, 
the  usefulness  of  the  leg  is  greatly  impaired,  although  in 
exceptional  cases  workmen  have  been  known  to  do  their 
ordinary  work  in  spite  of  the  false  joint. 

I  once  knew  a  mason — it  was,  to  be  sure,  before  the  time  of  the 
Accident-insurance  Law — wlio  mounted  a  scailolding  and  performed 
the  regular  duties  of  his  trade  in  spite  of  an  unhealed  fracture  of  the 
tibia.  He  kept  the  leg  put  up  in  plaster,  Avhieh  he  himself  prop- 
erly renewed.  After  the  lapse  of  two  years  the  Itones  appeared  to  the 
patient  to  be  firmly  united.  When  I  examined  him,  fifteen  years 
later,  on  the  occasion  of  another  injury,  I  was  able  to  confirm  his 
observation. 

Pseudo-arthrosis  of  the  leg  gives  rise  to  the  following 
symptoms  : 

A  false  point  of  motion  is  very  apparent,  both  to  the 
physician  and  to  the  patient  himself.  In  order  to  use  the 
leg  in  walking,  the  bones  must  be  held  in  position  by  a 
supporting  apjmratus  or  a  firm  bandage,  and,  in  addition, 
the  patient  finds  it  necessary  to  use  a  cane.  In  cases  of 
compound  fracture  the  point  of  fracture  is  usually  marked 
by  an  exostosis,  to  which  the  scar  is  adherent,  and  which 
is  likely  to  increase  gradually  in  size.  The  bones  below 
the  point  of  fracture — in  other  words,  the  lower  fragment 
of  the  leg-bones,  including  the  bones  of  the  foot — are 
poorly  nourished,  hence  the  aifected  foot  is  usually  found 
smaller  than  the  other  and  has  a  wasted  a])pearance.  The 
leg  is  also  atrophied  above  the  point  of  fracture,  but  less 
strikingly  so.  Tiie  footprint  is  much  reduced  in  size. 
For  several  months  the  skin  of  the  aifected  leg  remains 
cyanotic  and  cool  to  the  touch,  especially  below  the  point 
of  fracture.  As  the  cyanosis  gradually  disappears,  the 
skin  becomes  abnormally  pale  ;  this  is  most  noticeable 
on  the  sole  of  the  foot,  and  is  permanent.  The  tem- 
perature of  the  skin  also  remains  somewhat  reduced. 
If  the  false  joint  is  situated  quite   near  the  ankle-joint, 


448  DISEASES  CA  USED  BY  ACCIDENTS. 

complete  ankylosis  of  the  latter  may  result.  Occasionally 
pseudo-artlirosis  is  accomj)anied  by  a  great  deal  of  pain. 

Treatment. — When  union  is  delayed,  the  patient 
should  begin  to  walk  early,  the  leg  being  properly  sup- 
ported by  a  bandage  or  by  an  ajiparatus,  ^vhile  the  usual 
treatment  by  massage, baths,  and  electricity  is  not  neglected. 
Medicomechanical  gymnastics  should  be  practised,  if 
possible. 

Insurance  allowance  :  The  rate  is  necessarily  always 
high — from  50  %  to  60  %  or  over. 


6.  INJURIES  AND  TRAUMATIC  DISEASES  OF  THE  FOOT 
AND  ANKLE. 

ConHidcndions  on  Anatomy  and  Function. — The  weight  of  the  body 
is  transmitted  from  the  tiVjia  to  the  foot,  or  rather  to  the  astragalus, 
through  which  it  is  conveyed  to  the  hones  that  rest  upon  the  ground. 
When  at  rest,  the  dorsum  of  the  foot  jjresents  a  doultle  convexity,  and 
tlie  plantar  surface  a  double  concavity.  Its  shape  changes  the  moment 
the  weight  of  the  botly  is  put  upon  it;  the  convexity  of  the  dorsal  surface 
becoming  decidedly  diminished,  while  the  plantar  concavity  sinks 
downward  and  assumes  a  simpler  form;  the  outer  liorder  of  the  foot  is 
pressed  against  the  ground,  causing  the  outer  arch  to  disajipear.  The 
metatarsal  bones  and  phalanges  are  ])ushed  foiward  and  are  spread  out 
to  both  sides  in  fan-sliape,  making  the  foot  ai)pear  longer  and  broader. 
The  foot  in  this  jtosition  is  hollowed  out  underneath,  in  the  sliape  of  a 
half  dome,  directed  inward,  while  the  two  feet,  when  placed  together 
with  their  inner  borders  in  contact,  form  a  complete  dome. 

"Wlien  the  foot  changes  its  shape,  under  the  influence  of  the  weight 
of  the  body,  as  previously  described,  the  ligaments,  tendons,  and 
muscles  are  thereby  ])ut  on  the  stretch.  This  stretching  process  is 
limited  by  the  reflex  contraction  of  the  muscles,  especially  of  the  short 
muscles  of  the  foot.  If  the  weight  which  the  foot  is  called  upon  to 
sup])ort  is  excessive,  or  is  too  suddenly  applied,  the  foot  gives  way 
at  the  point  of  gi-eatest  pres.sure  or  of  least  resistance,  and  there  results 
a  rupture  of  the  ligaments,  or  a  fracture. 

The  shape  of  the  foot  in  the  ditt'erent  positions  which  it  assumes  in 
walking  varies  consideral)ly  from  that  which  characterizes  it  in  the 
upright  position  when  standing  still.  As  an  illustration,  let  us, 
without  entering  into  details,  take  the  position  of  the  foot  at  one 
special  moment  in  the  series  of  movements  executed  in  walking — 
when  one  foot  rests  on  the  ground  in  front  in  a  ))osition  of  inversion, 
the  knee  of  that  leg  being  flexed,  while  the  other  foot,  with  knee  ex- 
tended, is  sujtported  on  the  toes.  The  sha])e  of  the  two  feet  at  this 
moment  is  very  different.  The  parts  of  the  foot  which  especially 
eerve  to  preserve  the  balance  of  the  body  in  standing  are  the  posterior 


ANATOMY  OF  THE  FOOT.  449 

extremity  of  the  os  calcis  and  the  heads  of  the  first  and  fifth  metatarsal 
bones.  The  action  of  these  tliree  parts  accords  with  the  mathematic 
tlieory  of  the  preservation  of  balance  by  three  bases  of  supjiort. 

According  to  the  studies  of  H.  v.  Meyers,  the  arch  of  the  foot 
finds  its  chief  support  anteriorly  in  the  head  of  the  third  metatarsal 
bone,  an  assumption  which  he  ba<ses  on  the  fact  that,  if  all  the  other 
metatarsiil  bones  are  removed,  the  third  alone  furnishes  a  suffi- 
cient support  to  the  foot  in  standing.  It  is  undoubtedly  true  that 
many  individuals,  in  placing  their  feet  to  the  ground  in  walking,  bear 
their  weight  on  the  head  of  the  third  metatiirsal  })one.  Nevertheless,  as 
I  have  found  from  a  long  series  of  observations  on  normal  feet,  the  state- 
ment does  not  at  all  apply  to  the  majority  of  normally  built  people. 

The  union  between  the  bones  of  the  leg  and  those  of  the  foot  is 
formed  by  the  astragalus,  upon  which  the  tibia  rests,  and  which  is 
clasped  on  either  side  by  the  malleoli.  The  outer  surface  of  the  tibia, 
just  above  the  trochlear  surface  of  the  astragalus,  presents  a  depression 
extending  upward  for  about  the  width  of  two  fingers,  shaped  to 
correspond  to  the  inner  surface  of  the  fibula,  with  which  it  here  articu- 
lates, forming  the  inferior  tibiofibular  joint.  Tliis  is  not  a  joint  in  an 
anatomic  sense,  but  it  permits  of  certiiin  movements  of  the  fibula 
which  must  be  taken  into  consideration.  The  external  malleolus 
extends  lower  down  on  the  astragalus  than  the  internal,  and  is  more 
movable,  thus  giving  the  fibula  a  range  of  motion  at  the  ankle-joint 
greater  than  that  of  the  tibia.  The  fibula  mo\'es  slightly  up\vard  when 
the  ankle  is  flexed,  slightly  downward  when  it  is  extended,  and  rotates 
on  its  long  axis  during  adduction  and  abduction.  The  articular  surface 
of  the  astragalus  extends  further  downward  on  the  external  than  on 
the  internal  surface,  reaching  nearly  to  the  lower  border  of  the  bone, 
and  becoming  somewhat  convex  below,  at  which  point  the  ajiex  of  the 
external  malleolus  is  closely  approximated  to  it.  (See  Fractures  of  the 
Malleolus. ) 

The  trochlear  surface  of  the  astragalus  is  narrower  posteriorly  than 
anteriorly,  thus  allowing  of  rotatory  movement  of  the  ankle-joint  when 
the  foot  is  flexed  on  the  leg.  The  capsule  of  the  joint  is  attached  to 
the  margin  of  the  articular  cartilage;  it  hangs  loose  in  front  and 
behind,  becoming  tense  behind  when  the  foot  is  flexed  and  tense  in 
front  when  the  foot  is  extended.  An  effusion  in  the  joint  causes  the 
capsule  to  bulge.  Laterally,  the  capsule  is  reinforced  by  the  internal 
and  external  lateral  ligaments  respectively.  The  external  ligament 
consists  of  three  separate  bands,  the  interval  between  them  marking 
weak  points  in  the  capsule,  at  which  it  bulges  in  case  of  eft"usion,  and 
where  a  communication  with  the  posterior  calcaneo-astragaloid  articu- 
lation may  possibly  be  formed.  The  internal  lateral  ligament  (deltoid 
ligament)  is  much  stronger  than  the  external,  and  forms  a  continuous, 
firm,  fibrous  band,  closely  adherent  to  the  capsule  of  the  joint,  which 
is  attached  above  to  the  lower  border  of  the  internal  malleolus  and 
broadens  out  below  to  be  inserted  into  the  astragalus  and  os  calcis, 
sending  a  prolongation  forward  under  the  inferior  calcaneoscaphoid 
ligament,  to  which  it  is  attached,  to  the  scaphoid  bone.  Laceration  of 
this  ligament  unavoidably  opens  the  ankle-joint. 

29 


450  DISEASES  CAUSED  BY  ACCIDENTS. 

Immediately  under  the  inferior  calcaneoscaphoid  ligament  lies  the 
strong  tendon  of  the  tibialis  posticus  muscle,  which  is  inserted  into 
the  tuljercle  of  the  scaphoid. 

The  mobility  of  the  foot  chiefly  depends  on  the  ankle-joint  proper. 

The  following  movements  are  executed  at  the  ankle-joint. 

1.  Dorml  flexion. — Flexion. — The  dorsum  of  the  foot  is  drawn 
toward  the  leg,  forming  an  acute  angle.  Starting  from  the  position 
of  a  right  angle,  the  range  of  flexion  possessed  by  the  foot  equals  about 
25  degrees.  The  transverse  diameter  of  the  ankle  is  greatest  in  the 
flexed  position,  showing  the  malleoli  to  be  then  most  widely  sepa- 
rated. Rotation  can  not  take  place  in  this  position.  The  ligaments 
connecting  the  tibia  and  flbula  posteriorly  are  out  on  the  stretch. 
The  muscles  concerned  in  flexion  are  the  tibialis  anticus  and  peroneus 
tertius  (supplied  })y  the  anterior  tibial  nerve). 

^.  Plantarflexion. — Extemion. — The  dorsum  of  the  foot  is  drawn  away 
from  the  leg,  forming  an  obtuse  angle.  The  range  of  extension,  the 
starting-point  being  the  same  as  for  flexion,  equals  about  35  degrees. 
In  this  position  the  malleoli  clasp  the  narrowest  portion  of  the  troch- 
lear surface  of  the  astragalus  and  the  transverse  diameter  of  the  ankle- 
joint  is  diminished;  the  lower  ends  of  the  tibia  and  fil)ula  are  therefore 
brought  into  closer  apposition.  The  inferior  anterior  ligament  con- 
necting them  is  relaxed.  This  position  allows  of  rotatory  movements. 
Extension  is  produced  by  the  gastrocnemius  and  soleus  through  the 
medium  of  the  tendo  Achillis  (internal  popliteal  nerve). 

Flexion  and  extension  take  place  around  the  same  axis  passing 
through  tlie  trochlea  of  the  astragalus.  The  extreme  of  both  move- 
ments is  accompanied  by  movement  in  the  calcaneo-astragaloid  and 
mid-tarsal  joints. 

3.  Adduction. — The  tip  of  the  foot  is  drawn  inward  to  an  angle  of 
about  45  degrees.  During  adduction  the  internal  malleolus  moves 
slightly  backward  and  the  external  slightly  forward;  the  transverse 
diameter  of  the  malleoli  is  diminished,  the  inferior  tibiofibular  liga- 
ments are  put  on  the  stretch,  and  the  deltoid  ligament  becomes 
relaxed.  Adduction  is  accompanied  by  inversion  of  the  foot,  and  is 
produced  by  the  tibialis  anticus  (anterior  tibial  nerve)  and  tibialis 
posticus  (posterior  tibial  nerve). 

4-  Abduction. — The  tip  of  the  foot  is  drawn  outward,  to  an  angle  of 
about  50  degrees.  During  this  movement  the  internal  malleolus  moves 
slightly  forward  on  the  astragalus,  and  the  external  slightly  backward. 
The  transverse  diameter  of  the  malleoli  is  increased,  the  deltoid  liga- 
ment is  put  on  the  stretch,  and  the  anterior  inferior  tibiofibular  liga- 
ment is  relaxed.  Abduction  is  accompanied  by  eversion,  and  is  exe- 
cuted by  the  peroneus  longus  and  peroneus  brevis  (supplied  by  the 
peroneal  nerve). 

The  axis  of  rotation  in  adduction  and  abduction  remains  vertical 
Tip  to  the  point  marking  the  conuuencement  of  inversion  and  eversion 
of  the  foot.  The  two  latter  movements  take  place  in  the  mid-tarsal 
joint,  while  the  ankle-joint  is  fixed.  Adduction  and  abduction,  or 
inversion  and  eversion,  are  therefore  really  rotatory  movements. 

-5.  Circumduction,  made  up  of  all  the  four,  or  rather  six,  preceding 
movements,  in  which  the  tip  of  the  foot  describes  a  circle. 


SPRAINS  OF  THE  ANKLE.  451 

Movement  of  the  toes  is  limited  to  flexion  and  extension,  except  in 
the  case  of  tlie  metatarsophalangeal  joint  of  tlie  great  toe,  which  allows 
of  a  very  slight  degree  of  adduction  and  abduction. 

Walking  is  rendered  difficult  or  impossi))le  and  the  usefulness  of 
the  whole  limb  is  more  or  less  destroyed  by  deformity  or  stiffness  of 
the  foot  and  ankle  following  traumatism  or  disease. 


Sprains  of  the  Ankle=joint. 

(299  Cases.) 

It  is  only  of  recent  years  that  the  medical  profession 
has  begun  carefully  to  distinguish  between  true  sprains  and 
the  injuries  Avhich  formerly  were  mistakenly  diagnosed  as 
"  sprains,"  such  as  supramalleolar  fractures,  fractures  of 
the  malleoli,  and  fractures  of  the  os  calcis  or  astragalus. 
Even  at  the  present  day  such  mistakes  are  made  only  too 
often. 

One  of  the  most  striking  of  the  after-symptoms  of 
sprains  of  the  ankle-joint  is  weakness  of  the  joint,  which 
is  easily  accounted  for  by  the  strain  or  laceration  of  the 
ligaments  regularly  accompanying  the  lesion.  In  addi- 
tion, we  fiud  the  ankle-joint  swollen  and  painful,  the  joint- 
capsule  swollen,  and  the  mu.scles  atropiiied.  Usually, 
only  the  muscles  of  the  leg  are  affected  ;  occasionally,  the 
process  involves  the  whole  extremity. 

In  cases  of  slight  and  moderate  .severity  recovery  usu- 
ally takes  place  in  a  short  time. 

Insurance  allowance,  up  to  20^,  or  more  in  severe 
cases. 

There  is  a  typical  form  of  .severe  sprain,  in  which  heal- 
ing progresses  very  slowly,  and  of  M'hich  the  unfavorable 
results  are  very  persistent,  causing  a  relatively  high  rate 
of  incapacity  for  work. 

The  cause  of  these  sprains  is  to  be  sought  in  the  usual 
accidents — a  misstep,  turning  the  ankle  by  stepping  on  a 
small  stone,  alighting  on  the  feet  after  a  fall  or  a  leap 
and  turning  the  ankle.  The  only  point  of  difference  lies 
in  the  degree  of  violence.  The  severe  sprains  in  question 
involve  a  distinct   partial  dislocation  of  the  ankle-joint 


452  DISEASES  CAUSED  BY  ACCIDENTS. 

and  mid-tarsal  joint,  in  addition  to  the  usual  injury  to  the 
ligaments.  By  means  of  the  X-rays  we  are  al)le  to  de- 
termine the  exact  extent  of  the  displacement.  External 
examination  shows  an  abnormal  position  of  the  external 
malleolus  ;  it  appears  thickened,  as  if  it  had  been  the  seat 
of  a  fracture,  a  resemblance  which  is  heightened  by  the 
fact  that  the  transverse  diameter  of  the  ankle-joint  is 
shown  by  measurement  to  l)e  increased.  Not  infrequently 
we  find  the  internal  malleolus  thickened  also  and  its  out- 
lines indistinct.  In  the  majority  of  cases  the  foot  is 
slightly  inverted  ;  less  frequently  it  is  slightly  everted. 

In  the  former  case  a  careful  examination,  made  with 
the  feet  placed  parallel,  will  show  the  external  malleolus 
of  the  affected  fot)t  to  be  displaced  slightly  l)ackward  ;  if, 
on  the  contrary,  the  foot  be  everted,  the  malleolus  is  usu- 
ally found  to  be  displaced  forward,  its  posterior  border  is 
turned  slightly  outward,  and  the  tendons  of  the  peronei 
muscles  are  very  prominent.  If,  now,  we  examine  the 
patient  by  the  X-rays,  we  find  the  fibula  to  be  separated 
from  the  tibia  at  the  inferior  tibiofibular  joint,  so  that  it 
is  proper  to  speak  of  a  sul)luxation  of  this  joint.  The 
shaft  of  the  fibula  is  in  some  cases  closely  approximated 
to  the  tibia,  while  in  others  the  interval  between  the 
bones  is  increased  ;  the  anterior  extremity  of  the  os  calcis 
is  frequently  displaced  upward  at  the  calcaneocuboid  joint, 
the  head  of  the  astragalus  also  lies  higher  than  normal ; 
in  other  words,  there  is  a  subluxation  of  the  mid-tarsal 
joint.  The  displacement  of  the  external  malleolus  often 
affects  the  whole  fibula,  even  to  the  head  of  the  bone. 

As  already  stated,  we  find  the  foot  inverted  in  the 
majority  of  cases  of  sprained  ankle,  which  is  doubtless 
due  to  laceration  of  the  anterior  ligamentous  connections 
between  the  tibia,  fibula,  and  astragalus,  or  to  fragments 
having  been  torn  off  these  bones.  The  backward  dis- 
placement of  the  external  malleolus  naturally  causes  a 
certain  degree  of  outward  rotation  of  the  astragalus;  the 
OS  calcis,  too,  is  slightly  rotated  outward  on  its  long  axis, 


Fig.  9G. 


454  DISEASES   CAUSED  BY  ACCIDENTS. 


PLATE  38. 

Case  of  Atrophy  of  the  Back  and  Sole  of  the  Foot  after 
a  Fracture  of  the  Os  Calcis. 

A  workman,  twenty-four  years  of  age,  fell  from  a  scaffolding  one 
story  high  on  August  16,  1898,  sustaining  a  fracture  of  the  left  os 
calcis.  He  was  treated  at  first  in  the  hospital,  then  attended  my 
clinic  from  October  22,  1898,  until  April  20,  1899.  The  illustrations 
show  the  atrophy  of  the  muscles  of  tlie  left  foot  very  distinctly.  The 
alxluctor  pollicis  and  the  belly  of  the  extensor  communis  brevis  are 
particularly  affected.  The  toes  a})pcar  moi-e  closely  approximated 
than  on  tlie  normal  foot;  the  sole  is  narrowed,  and  is  somewhat  pale 
or  livid  in  color.  The  ])lantar  fascia,  which  normally'  can  be  tlistinctly 
traced,  is  not  evident  on  the  atrojjliied  foot.  The  reduced  size  of  the 
footprint  and  the  slight  flattening  of  the  arch  are  shown  in  figure  97. 


making  it  appear  thickened  externally,  as  if  it  had  been 
the  seat  of  a  compression-fracture.  The  position  of  the 
astragalus  naturally  affects  that  of  the  tibia,  and  we  there- 
fore iind  a  subluxation  of  the  ankle-joint.  The  tibia  is 
slightly  rotated  outward,  the  knee  on  the  injured  side  is 
in  some  cases  slightly  raised  above  the  normal,  the  same 
change  of  position  being  apparent  at  the  anterior  superior 
spine.  The  nmscles  appear  atonic,  or  even  greatly  atro- 
phied. Tiiis  is  most  noticeable  in  the  leg,  but  may  in- 
volve the  whole  extremity.  The  inversion  of  the  foot 
necessitates  walking  on  its  outer  edge ;  the  metatarsal 
bones  are  thereby  pressed  closely  together,  narrowing  the 
foot. 

Case  of  sprained  ankle,  complicated  by  dislocaiion  of  fhc  inferior  tibio- 
fibular joinl.     (Fig.  96,  p.  45:1 ) 

A  workman,  forty  years  of  age,  slipped  on  a  ladder  on  Janu- 
ary 25,  1898,  and  fell  from  the  fourth  rung,  spraining  his  ankle. 
He  was  treated  in  the  hosi)ital  for  seven  weeks;  splints  were  applied 
for  two  weeks  and  plaster  bandages  for  four  weeks;  he  was  allowed 
to  walk  in  the  eighth  week.  He  was  subsequently  treated  in  my 
clinic,  up  to  October  14,  1898.  The  swelling  of  the  ankle  subsided 
very  slowly,  and  the  patient  remained  lame  for  a  long  time.  The 
skiagraph  shows  the  upward  dis])lacement  of  the  head  of  the  astraga- 
lus and  the  anterior  extremity  of  the  os  calcis;  also  the  backAvard  dis- 
placement of  the  external  malleolus.     The  foot  was  inverted. 


7ab.:is. 


Fi^'A 


n,  2- 


i.un . .  \n.-ii-  r.  /it'iaUuiui.  Mujuinn . 


TREA  T3IENT  OF  SPRA  INS.  45  5 

In  slight  cases  of  sprain  the  usefulness  of  the  part  may 
be  only  impaired  sliglitly,  or  not  at  all.  Patients  are 
nsually  able  to  walk  without  ditKculty  in  five  or  six  weeks, 
although  they  continue  to  complain  of  pain,  which  they 
definitely  locate  in  the  ankle-joint,  and  of  inability  to 
carry  heavy  loads. 

The  effect  on  functional  power  of  severe  cases  of  sprain 
is,  on  the  other  hand,  very  considerable.  Lameness  is  a 
marked  symptom,  and  the  muscles  of  the  whole  extremity, 
and  especially  of  the  foot,  become  greatly  atrophied.  It 
may  be  six  months,  or  even  longer,  before  the  patient  is 
able  to  resume  work. 

Treatment. — Tlie  malposition  of  the  foot  should  be 
corrected  by  careful  bandaging,  or  the  patient  should  wear 
a  laced  shoe,  appropriately  padded.  In  addition,  medico- 
mechanical  exercises  on  an  apparatus,  massage,  electricity, 
etc.,  are  in  place. 

Insurance  allowance,  20  ^ .  If  the  patient  is  obliged 
to  use  a. cane,  50^  or  over. 

Apart  from  the  typical  displacement  of  the  ankle  in 
cases  of  sprain  (including  the  mid-tarsal  joint),  we  occa- 
sionally see  cases  in  which  the  appearances  simulate  a 
fracture  of  the  internal  malleolus,  although  the  latter  is 
quite  intact.  The  internal  malleolus  projects  distinctly 
and  its  outlines  are  not  well  defined  ;  as  a  rule,  there  is 
no  talipes  valgus.  If  a  skiagraph  be  taken  with  the  toes 
pointing  upward,  it  will  show  an  abnormally  wide  interval 
between  the  articular  surfiice  of  the  internal  malleolus 
and  the  internal  surface  of  the  astragalus.  Having  found 
the  external  malleolus  abnormally  movable  in  a  number 
of  these  cases,  I  conclude  that  the  malposition  is  due  to 
laceration  of  the  external  lateral  ligament  of  the  joint. 
Patients  are  usually  able  to  resume  work  within  a  few 
weeks.  A  firm  bandage  around  the  ankle  will  be  found 
very  helpful,  especially  during  working  hours. 

When  an  insurance  allowance  becomes  necessary,  a  rate 
of  from  10^  to  20^  will  usually  be  found  sufficient;  it 


456  DISEASES  CAUSED  BY  ACCIDENTS. 

seldom  needs  to  exceed  this.      Complete  recovery  is  to  be 
expected  within  six  months  in  average  cases. 

Dislocation  of  the  AnkIe=joint. 

Snbluxations'of  the  ankle-joint  proper  and  of  the  calca- 


Fig.  97. 

neo-astragaloid  and  mid-tarsal  joints  have  been  discussed 
under  sprains. 

Dislocations  of  the  ankle-joint,  if  properly  reduced, 
should  heal  without  difficulty,  and  leave  no  after-trouble ; 
but  in  some  cases  unfavorable  results  are  seen.  These 
usually  take  the  form  of  loose-jointedness,  or  of  stiffness 
and   restricted   mobility   of    the   ankle-joint.      The  latter 


DISLOCATION  OF  THE  ASTRAGALUS.  457 

condition  is  due  to  cicatricial  adhesions,  contractures,  or 
displacement.  Movement  of  tlie  joint  is  painful  and  pro- 
duces crepitus,  and  the  muscles  of  the  foot  and  leg,  or 
even  of  the  whole  extremity,  undergo  atrophy. 

The  treatment  is  symptomatic.  Insurance  allowance, 
about  20^. 

Lateral  dislocations  are  usually  complicated  with  frac- 
tures of  the  malleoli,  hence  the  similarity  of  the  after- 
symptoms  of  the  two  lesions,  as  displayed  in  talipes  valgus 
or  varus,  flexion  of  the  knee,  stiffness  of  the  joint,  and 
muscular  atrophy. 

Dislocation  of  the  Astragalus. 

One  form  of  lateral  dislocation  of  this  bone,  which  is- 
more  properly  spoken  of  as  a  subluxation,  is  apt  to  remain 
unrecognized,  and  to  be  seldom,  if  ever,  reduced,  although 
even  after  the  acute  symptoms  have  subsided  the  displace- 
ment remains  quite  noticeal)le.  The  injury  is  diagnosed 
as  "  dislocation  "  or  "  sprain  "  of  the  ankle-joint,  or  occa- 
sionally as  a  "  malleolar  fracture."  As  a  rule,  the  astrag- 
alus is  displaced  inward,  the  inner  edge  of  the  trochlear 
surface,  as  well  as  the  neck  and  head  of  the  l>one,  being 
distinctly  perceptible  on  the  inner  border  of  the  foot. 
There  is  a  slight  degree  of  talipes  valgus,  and  the  outlines 
of  the  external  malleolus  can  barely  be  discerned. 
Flexion  and  extension  of  the  ankle-joint  are  relatively 
well  preserved,  but  lateral  movement  is  restricted.  The 
muscles  of  the  calf  are  usually  found  atrophied.  It  is 
often  necessary  for  the  patient  to  wear  a  laced  boot  with 
an  appropriate  pad  ;  in  especially  severe  cases  side  sup- 
ports may  also  be  required. 

Insurance  allowance,  from  20^  to  25^,  on  the 
average. 

Subluxation  of  the  whole  bono  outward,  witli  conse- 
quent talipes  varus,  is  also  met  with,  l)ut  less  frequently 
than  the  form  previously  described,  and  usually  occurs  in 


458  DISEASES  CAUSED  BY  ACCIDENTS. 

connection  with  a  fractnre  of  the  external  malleolns  or 
shaft  of  the  fibula. 

Unreiluced  dislocations  of  the  astragalus  lead  to  serious 
functional  disability,  which  is  all  the  more  marked  if  the 
lesion  is  complicated  by  a  fracture.  (Compare  with 
Fractures.) 

Symptoms. — The  deformity  of  the  foot,  especially  at 
the  ankle,  is  very  striking;  the  leg  is  shortened  or  length- 
ened according  to  the  form  of  dislocation  ;  the  ankle  is 
stiff,  there  is  talipes  valgus  or  varus,  and  the  muscles  of 
the  whole  extremity  show  signs  of  atrophy.  Lameness 
is  a  marked  symptom. 

Treatment. — Reduction  should  be  performed  by  opera- 
tion. 

Insurance  allowance,  usually  50^  or  more. 

Dislocations  of  the  astragalus,  when  properly  reduced, 
usually  leave  the  joint  in  good  condition.  Adhesions, 
however,  sometimes  produce  ankylosis,  and  lead  to  mus- 
cular atrophy. 

If  the  head  of  the  astragalus  is  forced  through  the 
soft  parts  and  skin,  making  a  compound  dislocation,  there 
is,  of  course,  the  added  danger  of  infection  ;  even  if  this 
is  happily  avoided,  the  subsequent  stiffness  is  increased 
by  the  presence  of  an  adherent  scar. 

Other  unfiivorable  cases  are  followed  by  loose-jointed- 
ness. 

Typical  Fractures  of  the  Malleoli. 

(412  Cases.) 

Eversion-fractures,  in  which  the  fibula  is  fractured  just 
above  the  external  malleolus,  and  the  internal  malleolus  is 
torn  off  by  the  tension  of  the  deltoid  ligament,  are  caused 
by  the  ankle  being  violently  turned  inward,  the  foot  thus 
being  everted  and  carried  outward.  The  deformity  char- 
acteristic of  these  fractures  is  a  marked  feature,  even 
after  consolidation  takes  place. 


FRACTURES  OF  THE  iVALLEOLI.  459 

Symptoms. — At  the  time  when  the  patient  is  dis- 
missed from  surgical  treatment  he  is  usually  lame,  and 
may  be  unable  to  walk  at  all  without  the  support  of  one 
or  even  two  canes.  The  injured  foot  and  leg  are 
congested  and  edematous,  reddisli-blue  in  color,  and 
frequently  extremely  cold  to  the  touch.  The  whole  ex- 
tremity, from  the  buttocks  down,  is  noticeably  atrophied. 
The  foot  often  appears  small,  and  narrowed  across  the 
toes  and  metatarsus  in  consequence  of  the  atrophy  of 
the  muscles ;  while  the  sole  is  soft,  thin,  and  pale  or 
slightly  cyanotic.  If  the  patient  is  placed  on  a  high  stool, 
with  the  feet  parallel,  the  internal  malleolus  is  seen  to  be 
much  thickened  and  to  project  considerably  ;  it  is  also 
somewhat  directed  downward.  The  external  malleolus  ap- 
pears flattened  and  is  raised  in  proportion  as  the  inner  one 
is  depressed.  Just  above  it  a  distinct  depression  is  notice- 
able. In  many  cases  the  internal  malleolus  is  found  dis- 
placed forward,  the  external  malleolus  being  displaced 
backward  to  a  corresponding  degree ;  consequently,  the 
inner  border  of  the  dorsum  of  the  foot  is  more  or  less 
shortened.  The  astragalus,  having  lost  the  support  of  the 
deltoid  ligament,  sinks  somewhat  downward  and  inward, 
carrying  the  scaphoid  with  it.  In  short,  we  have  a  rota- 
tion of  the  foot  by  which  its  inner  border  is  lowered  and 
its  outer  border  correspondingly  raised.  The  articular 
surface  of  the  tibia  frequently  becomes  partly  displaced 
from  the  trochlea  of  the  astragalus,  and  the  mobility  of 
the  ankle-joint  is  restricted  or  completely  suspended.  Of 
the  movements  of  the  joint,  flexion  and  extension  are  rel- 
atively best  preserved,  lateral  movement  being  much 
more  seriously  aff^ected.  There  is  often  distinct  crepitus 
under  the  malleoli  perceptible  to  the  touch,  and  some- 
times loud  enough  to  be  heard  at  a  distance.  Lame- 
ness is  a  more  or  less  well-marked  symptom,  and  fre- 
quently depends  not  only  on  the  deformity  of  the  foot  as 
previously  descril)ed,  but  also  on  the  malposition  of  the 
knee-joint  and  hip-joint  that  accompany  it.      This   con- 


460 


DISEASES  CAUSED  BY  ACCIDENTS. 


sists  of  genu   valgum,  together  witJi   flexion  and  inward 

rotation  of  the  leg,  and  inward   rotation  of  the   head  of 

the  femur. 

The  after-treatment  for  these  typietd  malleolar  fractures 

may  extend  over  several  months,  or  even  a  whole  year  if 
the  individual  is  no  longer  young. 
A  laced  and  padded  shoe  should 
be  worn  to  prevent  an  increase  of 
the  deformity.  Splints,  by  reliev- 
ing the  foot  of  the  weight  of  tlie 
body,  sometimes  render  excellent 
service,  and  effect  a  more  rapid 
cure  than  could  otherwise  be  ac- 
complished. If  the  valgus  is 
exti'eme  and  the  patient  is  very 
stout,  it  is  well  to  strengthen 
the  inner  l)ar  of  the  splint  by  a 
small  horizontal  l)ar  running  from 
it  to  the  iieel.  This  also  adds 
considerably  to  the  support  of  the 
foot.  Massage,  electric  stinuda- 
tion  of  the  muscles,  and  medico- 
mechanical  exercises  are  also  of 
great  value.  Insurance  allowance, 
from  25^  to  33^,  or  more, 
depending  on  the  deformity. 

Tlie  accompanying  picture  (Fig.  98) 
illustratefs  the  case  of  a  workman,  thirty- 
four  3'ears  of  age,  who  .sustained  a  typical 
eversion-fracture  of  tlie  internal  malleolus 
caused  hy  a  \\heel  passing  o\cr  his  left 
ankle.  The  inner  malleolus  is  thickened 
and  very  prominent,  the  foot  is  displaced  outward,  and  the  muscles 
of  the  whole  extremity,  especially  of  the  leg,  are  atrophied. 

Case  of  iypical  ever>ii<)ti-fr<ic1ttrc  of  tlir  intcnia/  iitdllcohiK,  foUowcd  hi/ 
serious  functional  disahiliti/. 

The  accompanying  .skiagraph  (Fig.  f)!),  p.  4()1 )  shows  the  coiulition 
of  the  injured  parts  in  the  case  of  a  workman,  forty-nine  years  of  age, 
who  was  injured,  a.s  just  stated,  on  July  3,  1897,  when  a  cart  loaded 
with  stones  struck  his  right  leg.     He  was  treated  in  the  hospitiil  for 


Fig.  98 


Fig.  99. 


Fig.  100. 


Fig.  101. 


464  DISEASES  CAUSED  BY  ACCIDENTS. 

ten  weeks,  beginning  to  walk  six  weeks  after  tlie  accident,  the  ankle 
being  properly  supiwrted. 

I  examined  him  on  ()ctol)er  2,  1897.  The  deformity  is  snfficiently 
shown  in  the  skiagraph.  He  walked  on  the  inner  border  of  the  foot, 
and  the  ankle  was  extremely  stiff.  He  was  discharged  from  treatment 
on  Febrnary  22,  1898,  with  an  insurance  alloA\ance  of  33J%.  The 
gait  had  considerably  improved.  There  is  no  further  change  to  be 
reported. 

Case  of  typical  eversion-fracture  of  the  internal  malleolus.  ( Fig.  100, 
p.  462. )  ' 

A  druggist,  thirty-two  years  of  age,  when  discharging  a  commission 
in  a  new  building,  fell  with  a  scaffolding,  and  at  the  same  time  his 
left  ankle  was  struck  Ijy  a  board.  The  illustration  shows  a  well- 
marked  talipes  valgus ;  the  foot  is  much  displaced  outward;  the  internal 
malleolus  is  extremely  prominent.  The  ankle  was  stiff  at  first,  but  after 
a  course  of  treatment  its  mobility  was  siitisfactorily  regained.  The 
patient  was  sufficiently  recovered  to  })e  on  his  feet  from  early  in  the 
morning  until  late  in  the  evening  a  year  after  the  accident.  His  in- 
surance allowance  Avas  30 ^r  at  first  Ijut  was  reduced  to  15%  in  the  fol- 
lowing year.  The  whole  extremity  has  remained  considerably  atrophied, 
and  varicose  veins  are  beginning  to  show  in  l)oth  legs. 

The  accompanying  skiagraph  (Fig.  101,  ]).  4(53)  shows  a  very  severe 
case  of  typical  eversion-fracture  of  the  left  ankle,  with  subsequent 
complete  ankylosis.  The  patient  was  a  jjaintor,  forty-five  years  of 
age,  who  sustained  the  injury  in  question  hy  falling  down  a  flight  of 
stairs  on  July  27,  1896.  He  was  under  treatment  until  April,  1897, 
when  he  was  discharged  ^^■\th  an  insurance  allowance  of  33^%.  He 
was  exceedingly  lame  at-  first;  this  symptom  somewhat  diminished 
later  on.  No  important  change  has  taken  place  in  his  condition. 
The  skiagraph  was  taken  shortly  before  his  discharge. 

The  typical  inversion-fractures  of  the  external  malleo- 
lus are  produced,  as  are  many  sprains,  by  violently  turn- 
ing the  ankle  with  the  foot  inverted.  The  outer  edge  of 
the  trochlea  of  the  astragalus  strikes  against  the  inner 
surface  of  the  external  malleolus,  and,  as  the  external 
lateral  ligament  is  usually  strong  enough  to  resist  the 
strain,  the  malleolus  is  broken  off  just  above  the  border 
of  the  astragalus.  In  some  cases,  however,  tlu;  ligament 
gives  way  also.  The  mechanism  of  the  lesion  is  too  well 
known  from  text-books  on  fractures  and  dislocations  to 
need  discussion  here.  It  often  ])asses  unrecognized  under 
the  diagnosis  of  "  sprain."  Since  working-men  are  some- 
times known  to  continue  to  use  tlie  injured  foot  after  the 
accident, — walking  to  the  doctor  or  remaining  at   their 


INVERSION-FRACTURES.  465 

work, — trades-unions  are  often  inclined  to  discredit  the 
existence  of  a  fracture  and  to  fix  the  rate  of  insurance 
aHowance  proportionately. 

The  sequels  depend  altogether  on  the  accuracy  of  the 
diagnosis  and  on  the  treatment  that  is  instituted.  If 
the  injury  is  regarded  as  a  simple  sprain,  requiring  only 
rest  and  applications,  healing  is  likely  to  be  accompanied 
by  extensive  callous  thickening  of  the  external  malleolus, 
and  by  more  or  less  well-defined  inversion  of  the  foot. 
The  latter  is  a  marked  feature  of  some  cases,  especially 
of  those  accompanied  by  the  characteristic  displacements 
of  spraiii  and  by  dislocation  of  the  inferior  tibiofibular 
joint.  Occasionally,  the  fragment  of  the  malleolus  is  car- 
ried downward  and  slightly  backward  by  the  calcaneo- 
fibular  division  of  the  external  lateral  ligament,  leaving 
an  appreciable  interval  between  it  and  the  upper  fragment. 

Even  when  diagnosis  and  treatment  are  all  that  could 
be  desired,  cases  sometimes  occur  presenting  a  well-de- 
fined talipes  varus  after  recovery. 

In  contradistinction  to  this  fact  excellent  results  are 
sometimes  obtained  in  spite  of  continued  use  of  the  in- 
jured foot  and  an  entire  lack  of  treatment,  or,  at  the 
most,  a  bandage  around  the  ankle. 

The  talipes  varus  is  explained  by  the  change  of  rela- 
tion between  the  astragalus  and  the  external  malleolus, 
as  well  as  between  the  former  and  the  other  adjacent 
tarsal  bones,  and  made  still  more  clear  by  an  X-ray  ex- 
amination. The  deformity  of  the  foot  obliges  the  j^atient 
to  tread  more  or  less  on  its  outer  border ;  it  grows 
thinner  and  narrower ;  the  metatarsal  bones  change  their 
j)Osition  in  adapting  themselves  to  the  new  conditions 
from  above ;  the  whole  extremity,  even  including  the 
buttocks,  undergoes  atrophy,  and  genu  varum,  or  occa- 
sionally valgum,  is  frequently  observed.  Crepitus  under 
the  external  malleolus  persists  for  some  time,  and  mobil- 
ity of  the  joint  is  restricted.  Lameness  is  usually  evi- 
dent for  a  time  after  healing  of  the  fracture. 
30 


466  DISEASES   CAUSED  BY  ACCIDENTS. 

The  after-treatment  consists  of  local  vapor-baths  and 
medicomechanical  exercises,  by  means  of  which  the  symp- 
toms are  gradually  overcome.  The  malposition  is  best 
opposed  by  a  properly  padded  laced  shoe.  Patients  are 
able  to  resume  work,  as  a  rule,  within  from  four  to  six 
weeks,  although  cases  are  not  lacking  in  which  six  months 
and  even  longer  are  recpiired  for  treatment.  The  use- 
fulness of  the  joint  may  be  partly  or  even  completely  re- 
stored, while  its  general  anatomic  condition  remains  as 
previously  described.  Recovery,  in  the  sense  of  complete 
disappearance  of  all  the  symptoms,  may,  indeed,  never 
take  place. 

Average  insurance  allowance,  20^;  for  severe  cases, 
33|^  /^  or  more. 

Occasionally,  in  cases  of  eversion-fracturo,  a  bit  of  the 
tibia  is  broken  oif  from  the  outer  part  of  its  lower  ex- 
tremity at  the  same  time  that  the  fibula  is  fi-actured  just 
above  the  malleolus.  The  injury  to  the  tibia  at  this  point 
increases  the  danger  of  subsequent  stiffness  of  the  ankle- 
joint. 

Case  of  typicnl  invcrsion-fnicfure  of  fhc  left  ankle  {fraeture  of  the  ex- 
ternal malleol  iis) .      (Figs.  102  and  KK?,  p.  4()7. ) 

A  carpenter,  thirty-nine  years  of  age,  fell  from  a  scaffolding,  about 
nine  feet  high,  on  November  21,  IHiiO,  sustaining  the  fracture  just 
named.  When  I  examined  him,  on  February  24,  1891,  he  com])lained 
of  pain  in  the  outer  side  of  the  ankle,  running  up  to  the  middle  of 
the  knee.  The  external  malleolus  was  much  thickened,  the  internal 
one  had  disappeared.  The  foot  Mas  inverted  and  the  tendon  of  the 
tibialis  anticus  was  strongly  contracted.  The  muscles  of  the  whole 
extremity  were  atrophied  ;  the  left  anterior  superior  spine  and  the 
knee-joint  and  ankle-joint  were  elevated.  The  last-named  symptoms 
disappeared  in  the  course  of  time.  The  ankle-joint  was  partly  stiff,  and 
there  was  crepitation  under  the  external  malleolus  on  movement  of 
the  joint.  The  accompanying  illustrations  show  the  inversion  of  tlie 
foot  and  the  thickening  of  the  external  malleolus;  tlie  foot  also  appears 
narrowed  and  the  leg  wasted.  The  skiagraj)!!  sliowed  the  nliula  to  be 
considerably  displaced  ;  the  lo\\'er  extremity  was  separated  from  the 
inferior  tibiofibular  joint,  while  the  fibula,  as  a  whole,  which  had  be- 
come somewhat  curved  subseiiuenttothe  fracture,  was  closely  approxi- 
mated to  the  til)ia.  The  course  of  treatment  lasted  from  February  24, 
1891,  until  Augiist  14,  1891.  At  first  lameness  had  lieen  very  marked, 
and  the  patient  had  been  unable  to  walk  without  a  cane;  when  dis- 
charged, he  was  able  to  walk  much  Iietter. 

Insurance  alloAvance,  33^ '/c,  reduced  to  20;^   on  December  8,  1896. 


¥ig.  102. 


Fig.  103. 


468  DISEASES  CAUSED  BY  ACCIDENTS. 


Uncomplicated  Fractures  of  the  Malleoli. 

It  still  remains  to  speak  of  fraetures  of  the  malleoli 
alone,  uncomplicated  by  fracture  of  the  shaft  of  either 
the  tibia  or  fibula. 

These  fractures  are  produced  by  a  fall  or  leap  from  a 
height,  by  turning  the  ankle,  etc.  One  or  both  malleoli 
may  be  involved.  Very  frequently  the  fracture  remains 
unrecognized,  being  diagnosed  as  a  sprain,  and  sometimes 
the  patient  simply  binds  a  handkerchief  around  the  injured 
ankle  and  continues  to  work,  or  proceeds  on  foot  to  the 
doctor. 

Symptoms  after  healing  of  the  fracture  :  The  ankle 
remains  swollen,  the  outlines  of  the  malleolus  appear  in- 
distinct, the  depressions  on  either  side  of  the  tendo 
Achillis  are  filled  in,  pressure  on  the  aifected  malleolus  is 
likely  to  be  painful  and  there  is  pain  on  moving  the  ankle 
and  in  walking.  Crepitus  may  develop  somewhat  later, 
and  the  muscles  of  the  foot  and  leg,  and  possibly  of  the 
whole  extremity,  undergo  atrophy. 

Average  insurance  allowance,  20^. 

Fractures  of  the  Ankle=joint. 

The  first  class  of  these  fractures  to  be  considered  is 
that  in  which  the  whole  ankle-joint  is  involved,  or,  in 
other  words,  in  which  both  the  lower  extremity  of  the 
tibia  and  the  trochlear  surface  of  the  astragalus  are 
involved. 

Causes. — Falling  or  leaping  from  a  height,  from  a 
vehicle,  or  from  a  ladder ;  severe  crushing — caving  in, 
being  run  over,  etc. 

Symptoms  after  union  is  established  :  The  ankle-joint 
remains  swollen  and  thickened ;  the  leg  is  shortened ; 
there  is  talipes  valgus  or  varus  ;  the  foot  is  displaced  for- 
ward or  backward  ;  the  ankle-joint  is  stiff;  the  muscles 
are  atrophied,  and  the  patient  is  lame. 


FEACTUHES  OF  THE  ASTRAGALUS.  469 

Treatment. — This  is  directed  toward  the  recovery  of 
mobility,  and  inckides  local  baths,  massage,  gymnastics, 
and  electricity. 

Insurance  allowance,  from  30^  to  50^, 

Fractures  of  the  Astragalus. 

Whether  the  fractures  of  this  bone  involve  the  body  or 
the  processes  is  determined  by  the  form  of  violence  as  well 
as  by  its  intensity. 

The  body  of  the  astragalus  is  formed  of  very  dense 
cortical  substance,  and  in  the  great  majority  of  cases  a 
leap  or  fall  from  a  height  on  the  feet  causes  it  to  be  driven 
into  the  spongy  tissue  of  the  os  calcis.  In  other  cases 
the  body  of  the  astragalus  alone  is  fractured.  It  may  be 
fissured  or  broken  into  fragments. 

Fractures  of  the  body  may  be  confined  to  this  por- 
tion of  the  bone  or  may  extend  into  the  processes  or  to 
the  OS  calcis.  The  functional  prognosis  of  ordinary  longi- 
tudinal fissures  of  the  trochlea  is  good  ;  comminuted  or 
multiple  fractures  of  the  body,  on  the  other  hand,  invari- 
ably leave  the  joint  stiff. 

The  symptoms  are  as  follows  :  The  leg  is  shortened  ; 
the  whole  ankle  is  swollen  or  thickened,  making  the  out- 
lines of  the  malleoli  indistinct.  In  place  of  the  usual 
concave  curve  of  the  ankle-joint  in  front,  we  find  a  promi- 
nence at  this  point  between  the  back  of  the  foot  and  the 
leg ;  the  tarsal  sinus  appears  swollen  and  is  the  seat  of 
pain  (tarsalgia) ;  the  convexity  of  the  posterior  portion 
of  the  dorsum  of  the  foot  is  increased  ;  the  foot  is  atro- 
phied, as  is  the  whole  extremity,  and  the  patient  is  lame. 
Insurance  allowance,  from  33|^^  to  50^,  or  more. 

Fractures  of  the  astragalus  are  frequently  accompanied 
by  dislocation,  which  is  likely  to  produce  an  extreme  de- 
gree of  club-foot,  almost  destroying  its  usefulness.  (See 
Plate  40,  Fig.  2.) 

Symptoms. — If  the  tibia  rests  on  one  or  both  margins 
of  tjie  trochlea,  the  extremity  is  lengthened  ;  otherwise  it 


470  DISEASES  CAUSED  BY  ACCIDENTS. 

is  shortened.  There  is  club-foot  or  flat-foot,  sometimes 
accompanied  by  talipes  valgus.  The  length  of  the  back 
of  the  foot  is  diminished  or  increased,  the  hollow  at  the 
ankle  is  filled  in  and  painful ;  the  ankle-joint  is  stiff';  the 
muscles  are  atrophied,  and  the  patient  finds  it  difficult  to 
stand  or  to  walk.  If  the  extremity  is  lengthened,  the 
patient  is  unable  to  place  the  feet  parallel,  and  has  to  put 
the  injured  one  in  front. 

Insurance  allowance,  usually  over  50  ^ . 

Fractures  of  the  Neck  and  Head  of  the  Astragalus. 

These  lesions  are  met  with  far  more  frequently  than 
fractures  of  the  body,  which  is  partly  to  be  accounted  for 
by  the  preponderance  of  spongy  tissue  in  the  neck  of  the 
bone.  Fractures  of  the  neck  are  caused  not  only  by  such 
accidents  as  a  fall  or  leap  from  a  height,  but  also  by  much 
simpler  forms  of  traumatism,  such  as  turning  the  ankle, 
especially  when  the  foot  is  caught.  The  remote  symptoms 
dej)end  on  the  position  in  which  the  fragments  unite.  If 
the  head  of  the  bone  is  displaced  upward,  the  dorsum  of 
the  foot  appears  abnormally  arched  and  prominent.  If  it 
is  displaced  inward,  talipes  valgus  or  varus  results,  more 
often  the  latter.  One  form  of  fracture  of  the  neck  de- 
serves special  attention, — namely,  compression-fracture, 
— in  which  the  violence  acts  in  the  long  axis  of  the  foot. 
This  form  is  probably  never  met  with  except  in  cases 
of  caving-in. 

My  collection  includes  a  specimen  of  reunited  compression-fracture 
of  the  neck  of  the  astragalus,  the  scaphoid  also  shoeing  evidences  of 
compression.  I  also  once  happened  to  see  a  reunited  compression- 
fracture  of  the  neck  of  the  astragalus  in  a  su))ject  in  the  dissecting- 
room. 

Case  of  reunited  fracture  of  the  neck  of  the  afttr(if/alu.%  of  the  tubercle  on 
its  posterior  surface,  and  of  the  os  calcis,  caused  by  turning  the  ankle. 
Sequel,  complete  ankylosis  of  the  ankle-joint. 

A  hod-carrier,  twenty-seven  years  of  age,  when  carr\'ing  a  load  of 
lime  on  his  shoulder,  stepped  on  a  small  stone  and  turned  his  ankle. 
He  sustained  the  injuries  just  mentioned,  in  addition  to  a  sprain.  He 
was  treated  in  the  hospital  at  first,  coming  to  me  for  a  course  of  after- 


Fig.  104. 


472  DISEASES  CAUSED  BY  ACCIDENTS. 

treatment  on  December  27,  1890.  Tlie  injury  had  been  followed  by  a 
suppurative  inflammation  of  the  ankle-joint,  and  as,  in  addition,  the 
operation-scars  Avere  very  slow  in  healing,  the  course  of  treatment  was 
much  prolonged.     The  patient  was  discharged  on  December  18,  1891. 

The  accompanying  skiagraph  ( Fig.  104,  p.  471 )  shows  very  dis- 
tinctly the  line  of  fracture  on  the  neck  of  the  astragalus  ;  the  fracture 
of  the  OS  calcis  and  of  the  posterior  tubercle  of  the  astragalus  are  less 
plainly  visible. 

Insurance  allowance,  30^?,  which  the  patient  still  continues  to  re- 
ceive. 

Catie  of  fracture  of  the  os  calcis  and  neck  of  the  astragalus  due  to  a  fall 
from  a  second-story  icindow.     (Fig.  105,  p.  473.) 

A  painter,  twenty-three  years  of  age,  sustained  the  foregoing  inju- 
ries on  June  7,  1894,  and,  in  addition,  a  typical  fractiu-e  of  the  radius 
and  a  fracture  of  the  vertebra'. 

The  accompanying  skiagraph  (Fig.  105)  shows  the  line  of  fracture 
on  the  OS  calcis,  although  not  very  distinctly;  the  exostosis  on  the 
neck  of  the  astragalus  is  more  plainly  to  be  seen. 

The  course  of  treatment,  partly  on  account  of  the  a  arious  complica- 
tions, lasted  until  April  25,  1895, 

Total  insurance  allowance,  50^  .  The  patient  works  at  his  trade, 
but  his  working  capacity  is  limited. 

After  consolidation  of  fractures  of  the  neck  of  the 
astragalus  we  find,  on  palpation,  a  thick,  hard,  ring-shaped 
mass  in  front  of  the  ankle-joint,  especially  noticeable  in 
cases  in  which  the  head  of  the  astragalus  is  displaced 
upward.  The  ankle  appears  greatly  swollen,  and  is  likely 
to  be  quite  stiff.  This  is,  however,  not  necessarily  tiie 
case,  unless  the  lesion  occurs  in  connection  with  a  fracture 
of  the  malleoli.  The  talipes  valgus  or  varus  is  often 
accompanied  by  deformity  of  the  fiat-foot  or  club-foot 
variety.  In  cases  of  fracture  of  the  neck  due  to  compres- 
sion in  its  longitudinal  axis  we  find  the  foot  shortened. 
Fractures  extending  through  the  head  of  the  astragalus 
lead  to  ankylosis  of  the  astragalo-scaphoid  joint,  thereby 
restricting  or  abolishing  the  movements  of  inversion  and 
eversion  of  the  foot. 

Case  of  comminuted  fracture  of  the  neel-  of  the  astraf/altis.  (Fig.  106, 
p.  474. ) 

A  painter,  twenty-one  years  of  age,  fell  from  a  third-story  window 
on  July  22,  1896,  sustaining,  among  other  injuries,  a  fracture  of  both 
ankles.  The  accompanying  skiagraph  shows  the  fracture  of  the  neck 
of  the  left  astragalus.     The  patient  was  at  first  treated  in  the  hospital, 


Fig.  105. 


Fig.  106. 


FRACTURES  OF  THE  ASTRAGALUS.  475 

and  subsequently  received  treatment  under  my  direction  from  October 
20  until  December  12,  1896.  The  skiagraph  was  taken  at  the  time 
of  his  discharge.  There  was  a  decided  talipes  -sarus,  but  the  patient 
was  comparatively  little  inconvenienced  thereby,  and  could  walk  quite 
well. 

The  after-treatment  of  fractures  of  the  astragahis  may 
demand  considerable  time,  particidarly  when,  by  reason 
of  a  mistaken  diagnosis,  the  patient  was  allowed  to  walk 
too  soon.  This  is  unfortunately  not  so  infrequent  an 
occurrence  as  one  would  wish. 

A  laced  boot,  possibly  with  side  supports,  is  in  many 
cases  essential  at  first.  Exercise,  massage,  etc.,  to  over- 
come the  stiffness,  are,  of  course,  also  indicated. 

The  insurance  allowance  may  amount  to  from  25^  to 
33|^^  ;  in  severe  cases  a  considerably  higher  rate  may  be 
warranted. 

The  posterior  internal  tubercle  of  the  astragalus  is 
very  frequently  broken  off.  This  tubercle  contains  a 
groove  that  aifords  passage  to  the  tendon  of  the  flexor 
longus  pollicis,  while  the  tendon  of  the  flexor  communis 
digitorum  runs  along  its  border.  The  lesion  is  very  likely 
to  occur  in  connection  with  compression-fractures  of  the 
OS  calcis,  in  which  the  astragalus  becomes  impacted  in  the 
former  bone.  Occasionally,  the  fracture  in  confined  to  the 
process,  in  which  case  it  is  due  to  turning  the  ankle, 
usually  to  turning  it  inward,  the  foot  being  forcibly 
everted.  Sometimes  the  tubercle  is  not  only  broken  off, 
but  is  displaced  by  nearly  one  centimeter  toward  the  pos- 
terior extremity  of  the  os  calcis. 

The  lesion  can  subsequently  be  recognized  by  a  swell- 
ing or  prominence  behind  the  internal  malleolus,  which 
is  most  apparent  when  the  feet  are  placed  parallel  and 
viewed  from  behind.  This  point  is  usually  sensitive  to 
pressure.  Flexion  of  the  great  toe  is  sometimes  inter- 
fered with. 

When  only  the  tubercle  is  involved,  the  patient  is  usu- 
ally not  incapacitated  for  work.  An  insurance  allowance 
of  15^    for  three   mouths  is  usually  sufficient  for  the 


476 


DISEASES  CAUSED  BY  ACCIDENTS. 


cases  in  which  the  symptoms  consist  of  slight  swelling, 
slight  talipes  valgus,  partial  inability  to  flex  the  toes,  and 
moderate  muscidar  atrophy  of  the  leg. 

It  should  be  remembered  that  fractures  of  the  astraga- 
lus are  very  often  overlooked,  and  are  frequently  difficult 
to  diagnose.  They  are  often  concealed  under  the  diagno- 
sis of  "  sprain  "  or  "  malleolar  fracture." 


Fig.  107. 


Scars  of  the  Ankle. 

Extensive  scars  over  the  ankle,  or  scars  in  this  location 
which  are  deeply  attached  to  the  underlying  tissues,  have 
an  extremely  unfavorable  influence  upon  the  circulation  of 
the  foot  and  upon  the  action  of  the  joint.  The  latter  may 
be  completely  immobilized  ;  the  foot  becomes  atrophied, 


WOUNDS  OF  THE  FOOT.  477 

and  the  foot  and  leg  appear  congested.  Scalds,  fol- 
lowed by  prolonged  suppuration,  and  cellulitis  are  the 
chief  causes  of  such  extensive  growths  of  cicatricial 
tissue.  The  insurance  allowance  varies  from  25  fo  to 
50^,  according  to  the  severity  of  the  symptoms. 

Dislocation  of  the  Peronei  Tendons. 

The  peronei  tendons  are  occasionally  displaced  in  con- 
nection with  sprains  of  the  ankle,  fractures  of  the  ex- 
ternal malleolus  or  fractures  of  the  tubercle  on  the  external 
surface  of  the  os  calcis.  It  is  rare  for  the  dislocation  to 
occur  by  itself.  If  there  is  much  pain,  the  tendons  should 
be  sutured  in  position  ;  sometimes,  however,  the  displace- 
ment gives  rise  to  no  trouble  whatever.  After  fractures 
of  the  external  tubercle  on  the  os  calcis,  there  is  danger 
of  the  tendons  becoming  involved  in  the  callus,  in  which 
case  the  action  of  the  muscles  is  abolished.  (See  Separa- 
tion of  the  Tubercle  on  the  External  Surface  of  the  Os 
Calcis.) 

Case  of  partial  disJocaUon  of  the  tendon  of  the  peroneus  longus,  due  to 
fracture  of  the  os  calcis. 

By  looking  closely  at  the  accompanying  illustration  (Fig.  107)  the 
tendon  of  the  peroneus  longus  can  be  recognized  above  the  external 
malleolus.     The  displacement  gave  rise  to  no  symptoms  in  this  case. 

Traumatic  Achillodynia. 

This  term  indicates  an  inflammation  of  the  bursa  just 
above  the  insertion  of  the  tendo  Achillis,  lying  between 
it  and  the  posterior  extremity  of  the  os  calcis.  In  some 
cases  the  symptoms  are  inconsiderable  ;  in  others,  the 
patients  complain  of  very  severe  pain.  Suppuration  may 
be  induced  by  irritating  pressure  of  the  shoe. 

Wounds  and  Scars  of  the  Foot. 

(Fifty-seven  Cases  of  Wounds  of  the  Dorsum  and  Sole  of  the  Foot 
without  Injiiry  of  the  Bones. ) 

The  danger  of  infection  in  cases  of  wounds  of  the  foot 
is  evident,  especially  in  individuals  of  uncleanly  personal 


478  DISEASES  CAUSED  BY  ACCIDENTS. 

habits.  Prolonged  suppurative  processes  and  edema  of 
the  foot  and  leg  are  the  consequences  to  be  feared. 

Treatment. — Rest  in  bed,  careful  cleansing  of  the  part, 
and  antiseptic  dressings  are  indicated.  Compresses  wet 
with  a  solution  of  acetate  of  alum  are  very  serviceable. 

The  eifect  of  the  scar  on  the  functional  action  of  the  foot 
varies  with  its  location.  A  scar  at  the  point  of  origin  of 
the  extensor  communis  brevis  interferes  with  extension 
of  the  toes,  and,  to  even  a  greater  extent,  with  their  flexion 
and  with  the  bending  of  the  tip  of  the  foot  downward. 
(See  Plate  40,  Fig.  1.)  The  mobility  of  the  toes  also 
suffers  when  a  scar  of  the  metatarsal  region  reaches  deeply 
into  the  tissues,  and  at  the  same  time  the  circulation  of 
the  part  is  interfered  with.  Scars  of  the  plantar  surface 
render  walking  painful,  and  are  always  liable  to  break 
open. 

The  insurance  allowance  is  proportionate  to  the  loss  of 
functional  power,  being  especially  influenced  by  the  effect 
of  the  lesion  on  walking  (on  whether  a  cane  is  required). 

Crushing  of  the  Foot  and  Toes. 

When  crushing  is  not  severe,  the  injured  part  is  soon 
restored.  If,  however,  the  foot  is  severely  crushed  under 
heavy  objects,  such  as  a  beam,  an  iron  rail,  a  block  of 
granite,  the  wheel  of  a  vehicle,  etc.,  the  results  are  likely 
to  be  serious.  Fractures  of  the  tarsal  or  metatarsal 
bones  or  of  the  ])halanges  are  usually  produced,  the 
fractures  frequently  being  compound  and  the  parts  so 
badly  mangled  as  to  require  amputation.  (See  Plate  39, 
Figs.  1  and  2.) 

Even  when  the  bones  remain  intact,  the  extravasations 
of  blood  and  injuries  of  the  tendons  are  calculated  to 
render  the  foot  useless  for  some  time  afterward. 

Laceration  of  the  Plantar  Fascia. 

The  fascia  is  sometimes  torn  when  the  foot  is  badly 
crushed,  or  when  the  os  calcis,  for  instance,  is  broken  by 


SUBLUXATION  OF  THE  OS  CALCIS.  479 

a  fall  on  the  feet.  The  lesion  is  subsequently  to  be  recog- 
nized by  a  hard,  nodular  growth,  the  size  of  a  bean  or 
even  larger,  on  the  inner  border  of  the  foot  where  the 
fascia  is  made  tense  by  flexing  the  foot.  For  a  time  this 
is  very  painful,  both  in  standing  and  walking,  and  the 
patient  may  be  unable  to  walk  at  all,  unless  supplied  with 
a  properly  padded  shoe.  The  pain,  however,  diminishes 
in  the  course  of  time. 

Dislocation  of  the  Subcalcaneoid  Bursa. 

I  have  seen  one  case  of  this  lesion.  Xormally,  the 
bursa  lies  on  the  under  surface  of  the  posterior  portion  of 
the  OS  calcis. 

A  hod-carrier,  forty-seven  years  of  age,  in  carrying  a  load  of  stones 
on  his  shoulder,  made  a  misstep,  striking  the  left  heel  very  forcibly 
against  the  edge  of  a  ditch.  The  part  became  painful,  and  he  applied 
compresses.  When  I  examined  the  patient,  on  November  22,  1897,  I 
found  the  under  surface  of  the  os  calcis  slightly  thickened ;  as  he  raised 
the  heel  from  the  ground  in  walking  a  cracking  sound  was  produced, 
which  could  be  heard  at  a  distance  of  about  six  feet.  The  bursa, 
which  was  displaced  forward,  was  removed  and  the  sound  disappeared. 

Subluxation  of  the  Os  Calcis. 

Partial  dorsal  dislocation  of  the  os  calcis  at  the  calca- 
neocuboid articulation  is  a  lesion  very  frcf^uently  met 
with,  usually  as  a  symptom  of  other  injuries  of  the  foot, 
such  as  fracture  of  the  os  calcis,  simple  spi-ain  of  the 
ankle,  or  sprain  complicated  with  malleolar  fracture  or 
fracture  of  the  astragalus.  The  displacement  can  best  be 
determined  by  means  of  the  X-rays. 

The  astragalus  is  almost  always  secondarily  displaced 
to  a  corresponding  degree ;  the  outer  anterior  angle  of  the 
greater  process  of  the  os  calcis  is  more  prominent  on  the 
injured  foot  than  on  the  normal  one,  and  lies  higher.  In 
addition,  the  os  calcis  is  frecptently  slightly  rotated  out- 
ward on  its  long  axis.  The  position  of  the  malleoli, 
especially  the  outer  one,  is  also  affected.  The  symptoms 
of  the  subluxation — which,  in  fact^  is  often  more  evi- 


480  DISEASES  CAUSED  BY  ACCIDENTS. 

denced  by  the  astragalus  than  by  the  os  calcis  itself — are, 
as  a  rule,  of  no  great  moment  after  the  subsidence  of 
the  inflammation  and  swelling.  Some  patients,  however, 
more  sensitive  than  others,  continue  to  complain  of  con- 
siderable pain,  which  is  most  severe  when  they  walk  and 
stand,  and  for  such  a  more  extensive  course  of  after- 
treatment  is  required.  Rest,  compresses,  regular  massage, 
and  medicomechanical  exercises  are  usually  successful  in 
promoting  recovery.  A  laced  shoe  with  side  supports  is 
advisable  for  some  cases.  If  the  part  remains  painful,  in 
spite  of  regular  treatment,  it  is  best  to  dismiss  the  patient 
with  a  temporary  insurance  allowance  of  from  20  fo  to 
30^.  As  a  rule,  the  symptoms  disappear  soon  afterward, 
and  the  patient  recovers  full  working  capacity. 

Fractures  of  the  Os  Calcis. 

(145  Cases.) 

For  anatomic  as  well  as  practical  reasons  it  is  best  to 
divide  the  fractures  of  the  os  calcis  into  those  of  the  body 
and  those  of  its  processes.  Fractures  of  the  body  fre- 
quently involve  the  processes  also,  while  the  latter  are 
often  broken  without  other  injury  to  the  bone. 

Fractures  of  the  body  are  almost  invariably  of  the 
class  of  compression-fractures,  the  violence  acting  upon 
the  bone  in  a  vertical  line,  while  at  the  same  time  the 
astragalus  is  driven  into  its  cancellous  tissue.  The  lesion 
is  usually  occasioned  by  alighting  on  the  heel  after  a  fall 
or  a  leap  from  a  height.  The  os  calcis  may  alone  be 
affected,  or  the  fracture  may  involve  the  adjacent  bones — 
the  astragalus  and  malleoli  and  the  lower  end  of  the 
tibia. 

Case  of  compression-fracture  of  the  os  calcis.  The  illustration  (Fig. 
108)  shoAvs  the  left  os  calcis  to  be  greatly  broadened  and  thickened. 

The  patient  in  this  case  was  a  carpenter,  forty-fonr  >ears  of  age, 
who  had  fallen  from  a  scaffolding  seven  feet  high  on  September  21, 
1894,  landing  on  the  feet.  He  was  treated  at  home  at  first,  subse- 
quently attending  my  clinic  from  December  21,  1894,  until  August 


FRACTURES  OF  THE  OS  C ALOIS. 


481 


24,  1895.     Insurance  allowance,  33 j  ^/r ,  which  was  reduced  in  October, 
1898,  to  25%. 

The  accompanying  sole-impressions  (Fig  109,  p.  482)  illustrate  the 
case  of  a  carpenter,  thirty -nine  years  of  age,  who  sustained  a  compression- 
fracture  of  the  right  os  calcis  on  December  18,  1893,  as  a  result  of  a  fall 
from  a  ladder.  The  heel  sul)sequently  became  coiisideraJjly  (broadened  ; 
talipes  varus  and  flat-foot  developed.  The  impressions  of  the  soles 
show  the  thickening  of  the  heel  and  the  difierence  between  the  two 
soles,  the  outer  Ijorder  of  the  affected  one  approaching  the  outer  boun- 
dary-line.    Insurance  allowance,  33j.  fo 

Symptoms  after  con- 
solidation :  At  first  the 
foot  is  swollen,  especially 
around  the  ankle  and  over 
the  heel,  the  swelling  ex- 
tending to  the  leg  as  well. 
The  OS  calcis  appears 
broadened,  particularly  at 
its  posterior  extremity, 
and  the  tubercles  on  its 
under  surface  may  be 
thickened.  Similar 
thickening  of  the  astrag- 
alus and  the  malleoli  is  to 
be  observed,  if  these  were 
involved  in  the  fracture. 
The  leg  is  shortened  in 
proportion  to  the  loss  of 
height  of  the  os  calcis,  the 
malleoli  lie  on  a  lower 
plane  than  normally,  and 
the    depressions  on  either 

side  of  the  tendo  Achillis  are  filled  out ;  the  anterior  portion 
of  the  foot,  especially  its  tip,  is  narrowed.  More  or  less 
well-defined  flat-foot  is  a  common  l)ut  not  an  invariable 
symptom  ;  talipes  valgus  or  varus  or  talipes  planus  varus  are 
sometimes  observed,  more  particularly  in  cases  complicated 
by  fracture  of  the  malleoli.  Added  sym])toms  are  atrophy 
of  the  sole,  cicatricial  nodules  in  the  plantar  tascia,  dis- 
31 


Fig.  108. 


Fig.  109. 


Fig.  110. 


484  DISEASES  CAUSED  BY  ACCIDENTS. 

location  of  the  tendons  of  tlie  pcronei  opposite  the  external 
malleolns,  atrophy  of  the  muscles  of  the  leg,  especially  of 
the  calf,  and,  in  most  cases,  muscular  atrophy  of  the  thigh 
and  buttocks  also.  Paresthesia,  such  as  sensations  of  cold, 
formication,  venous  congestion,  etc.,  may  also  be  in  evi- 
dence. Flexion  and  extension  of  the  ankle-joint  are 
usually  only  slightly  aifected,  whereas  rotatory  movements, 
or  circumduction,  are  restricted  or  quite  suspended.  In- 
version and  eversion  of  the  foot  are  likely  to  be  more  or 
less  abolished,  and  if  ossification  takes  place  between  the 
astragalus  and  os  calcis,  they  can  never  be  recovered. 
The  gait  is  often  very  unnatural  at  first ;  the  foot  is  fre- 
quently held  abducted  in  walking. 

Treatment. — From  the  first  the  patient  sliould  be 
warned  by  the  surgeon  against  standing  or  walking  until 
it  is  quite  safe  to  use  the  injured  foot.  This  is  especially 
true  of  large,  heavy  individuals,  in  whom  slow  recovery 
and  poor  results  are  frequently  attril)utable  solely  to  neglect 
of  this  precaution.  A  shoe  with  side  supports  should  be 
worn  for  a  time ;  if  the  under  surface  of  the  os  calcis  is 
thickened,  this  should  be  allowed  for  by  an  appropriate 
pad.  If,  nevertheless,  relief  is  not  afforded  and  the 
patient  is  unable  to  walk,  the  exuberant  callus  should  be 
chiseled  off.  Vapor  baths,  electricity,  and  massage  should 
be  employed  as  usual. 

The  patient  may  be  sufficiently  incapacitated  for  work 
to  warrant  an  insurance  allowance  of  from  20^  to  50^, 
or  even  more ;  if  there  is  only  slight  difficulty  in  walking 
and  standing,  20  fo  should  suffice. 

Case  of  fracture  of  the  os  calcis  and  dislocnfion  of  the  external  malleo- 
lus; also  jmrtial  fracture  of  the  posterior  extremifji  of  the  os  ealeis  due  to 
muscular  action.     (Fig.  110,  p.  483.) 

A  polisher,  forty-eight  years  of  age,  fell  from  a  scaffolding  about  five 
feet  high  on  March  13,  1896.  When  I  examined  liim,  on  April  23,  1896, 
I  found  the  left  os  calcis  broader  than  normal,  the  malleoli  somewhat 
thickened,  and  the  external  one  displaced  backward;  the  leg  was 
slightly  shortened,  and  there  was  a  tendency  to  talii)es  valgus.  Step- 
ping on  the  foot  caused  pain  in  the  os  calcis;  the  foot  could  not  be 
inverted  and  everted.     The  skiagraijh  shows  the  line  of  fracture  in  the 


Fit;.  111. 


486  DISEASES  CAUSED  BY  ACCIDENTS. 

anterior  portion  of  the  os  calcis  very  beantif ully ;  it  also  shows  a  small 
portion  of  bone  to  be  lacking  from  the  upper  part  of  the  posterior 
extremity  of  the  os  calcis.  The  patient  was  nnder  treatment  from 
June  6,  1896,  until  January  25,  1897.  Insurance  allowance,  at  first, 
50  fo  ;  reduced,  on  May  10,  1897,  to  30%. 

Caac  of  fracture  of  the  posterior  extremitij  of  the  os  calcis  due  to  mus- 
cular violence. 

In  the  skiagraph  (Fig.  Ill,  \).  485)  we  can  see  the  gap  in  the  pos- 
terior extremity  of  the  os  calcis.  The  lesion  occurred  on  January  21, 
1897,  when  the  patient,  a  mason,  thirty-eight  years  of  age,  fell  from  a 
scaffolding  about  five  feet  high.  He  was  treated  at  home  with  com- 
presses and  inunctions,  remaining  in  bed  for  a  week.  The  course  of 
after-treatment  lasted  until  August  21,  1897,  when  he  was  discharged 
with  an  insurance  allowance  of  25 % .  He  was  af ter\\ard  able  to  do 
the  regular  work  of  a  mason  without  difficulty.  His  allowance  was 
reduced  to  15%  in  June,  1898,  and  has  since  then  been  entirely  dis- 
continued. The  symptoms  were  slight  stiffness  of  the  left  ankle-joint 
and  slight  atrophy  of  the  leg.  In  the  summer  of  1897  the  gap  in  the 
OS  calcis  was  much  larger  than  it  appears  in  the  skiagraph,  reacliingto 
about  the  middle  of  the  Ijone,  and  the  posterior  extremity  of  the  bone 
presented  a  distinct  callosity. 

The  posterior  extremity  of  the  os  calcis  is  sometimes 
broken  off  by  violent  contraction  of  the  mnscles  of  the 
calf  in  connection  with  a  fall  or  blow  on  the  heel,  the 
lesion  being  primarily  dne  to  the  direct  violence.  The 
bone  subseqnently  becomes  considerably  thickened  from 
above  downward  and  the  tendo  Achillis  passes  upward 
over  it  in  a  curved  line,  with  tlic  concavity  of  the  curve 
directed  upward.  If  a  skiao;i'a])h  is  taken,  we  see  a  tri- 
angular interval  in  the  bone,  in  shape  like  an  "  ojxii  duck- 
bill." Pressure  of  the  shoe  on  the  skin  over  the  thick- 
ened bone  is  likely  to  produce  an  ulcer  or  a  callosity. 
Unless  there  arc  complications,  the  working  capacity  of 
the  patient  is  usually  l)ut  slightly  affected. 

In  some  cases  of  transverse  fracture  of  the  os  calcis  the 
posterior  fragment  is  drawn  upward,  its  sharp-edged  end 
being  so  directed  downward  as  to  make  walking  painful 
or  even  impossible. 

If  the  OS  calcis  resists  the  violent  contraction  of  the 
calf  muscles,  the  muscles  themselves  may  give  way  in- 
stead, the  rupture  usually  occurring  at  the  point  of  their 
insertion  into  the  tendo  Achillis.     In  some  cases  we  find 


FRACTURES  OF  THE  OS  C ALOIS. 


487 


the  muscle  ruptured  and  the  broken  extremity  of  the  os 
calcis  dispkiced  upward  at  the  same  time. 

The  point  of  rupture  in  the  calf  is  marked  by  a  thick- 
ening of  the  muscles  or  by  an  interval  between  the  rup- 
tured portions.  In  the  first  instance  we  find  a  contracture 
of  the  muscles  and  flexion  of  the  knee,  causing  a  certain 
degree  of  talipes  equinus  ;  in  the  second  the  ruptured 
muscle  becomes  extremely 
atrophied.  Shortening  of 
the  sole  of  the  foot,  or, 
rather,  a  diminution  of  the 
surface  used  in  walking,  is 
a  characteristic  symptom  of 
upward  displacement  of  the 
posterior  extremity  of  the 
OS  calcis.  This  is  best 
demonstrated  l)y  an  impres- 
sion of  the  sole  made  on 
paper  coated  with  lamp- 
black. 


'a^  ;I 


4 


'■iu 


K  » 


f'^;, 


Case  of  fracture  of  the  posterior  If       H 

extremity  of  the  os  calcis,  due  to 
muscular  violence,  accompanied  by 
partial  rupture  of  the  muscles  of 
the  calf  at  the  point  of  their  inser- 
tion into  the  tendo  Achillis.  (Fig. 
112.) 

A   workman,    fifty-four   years 
of  age,    sustained   the   foregoing  ^^      _, 

injuries  on  April  27,  1895,  when,  '°' 

in    throwing    liimself    backA\ard 

on  a  wall  from  which  he  was  in  danger  of  falling,  he  struck  his  right 
heel  against  a  slab  of  granite.  The  illustration  shows  the  thickened 
extremity  of  the  os  calcis  and  the  increased  size  of  the  tendo  Achillis; 
also  the  atrophy  of  the  calf  muscles.  In  addition,  the  knee  being 
held  somewhat  flexed,  tlie  patient  was  unable  to  extend  it  completely; 
flexion  and  extension  of  tlie  ankle-joint  wej-e  limited,  and  the  sole 
of  the  foot  was  atrophied.  He  walked  with  a  limp.  The  course  of 
treatment  lasted  from  June  4,  1895,  until  December  21,  1895.  The 
ankylosis  of  the  knee  and  limited  i)ower  of  extension  were  entirely- 
cured.     Insurance  allowance,  33j%. 

The  accompanying  sole-impressions  (Figs.  113  and  114,  p.  489)  illus- 


488  DISEASES  CAUSED  BY  ACCIDENTS. 

trate  the  ca.se  of  a  workman,  thirty-eight  years  of  age,  who  fractured  the 
posterior  extremity  of  the  right  os  calcis  by  slipping  from  a  board  on 
December  10,  1895.  The  fracture  was  accompanied  by  marked  up- 
ward displacement.  The  impression  in  figure  113  shows  the  limited 
use  of  the  heel  in  walking,  in  consideration  of  which  an  insurance 
allowance  of  50%  was  granted  by  the  court.  Walking  was  very  diffi- 
cult at  first,  but  became  quite  easy  later  on. 

On  April  17,  1897,  the  patient  again  injured  the  same  foot,  on  this 
occasion  sustaining  a  fracture  of  both  malleoli,  as  well  as  a  fracture  of 
the  OS  calcis.  This  injury  liad  an  excellent  result,  as  shown  by  figure 
114,  the  foot  regaining  an  almost  normal  position  for  walking.  The 
insurance  allowance  was  therefore  reduced  to  15%. 

Fractures  of  the  greater  process  usually  occur  iu  con- 
nection with  fractures  of  the  body.  If  its  articular  sur- 
face is  involved,  the  calcaneocuboid  joint  is  likely  to 
remain  ankylosed,  entailing  a  permanent  loss  of  the  move- 
ments of  inversion  and  eversion  of  the  foot.  In  rare 
instances  a  severe  sprain  may  cause  a  fracture  of  the 
greater  process  alone. 

Fractures  of  the  sustentaculum  tali  are  frequently  ob- 
served as  an  accompaniment  of  the  so-called  comj^res- 
sion-fractures  previously  described.  They  may  occur  as 
separate  lesions,  although  infrequently  ;  I  have  myself, 
however,  seen  a  number  of  such  cases.  The  functional 
importance  of  this  fracture  is  easily  explained  by  the 
anatomic  relations  of  the  process.  If  the  whole  process 
is  broken  off, — which  is  fortunately  a  very  rare  accident, — 
the  astragalus  is  deprived  of  its  su})port,  and  slips  down- 
ward and  inward,  causing  the  foot  to  become  everted. 
The  inferior  calcaneoscaphoid  ligament  is  partly  torn,  or, 
at  any  rate,  becomes  relaxed,  and  the  deltoid  ligament  is 
also  lacerated.  In  consequence  of  these  injuries  to  the 
ligaments  passing  from  the  os  calcis  to  the  scaphoid,  the 
latter  bone  lacks  proper  support.  There  is  always  danger 
of  injury  to  the  tendon  of  the  flexor  communis  digitorum, 
which  passes  down  on  the  border  of  the  sustentaculum, 
and  to  that  of  the  flexor  longus  pollicis,  which  runs  in  a 
groove  on  its  under  surface.  If  the  sustentaculum  is 
badly  crushed,  the  tendons  are  likely  to  be  overgrown  by 


490 


DISEASES  CAUSED  BY  ACCIDENTS. 


callus,  leading  to  contracture  of  the  toes. 
found  a  well-marked  hallux  flexus. 


In  one  case  I 


Case  of  comminuted  fracture  of  the  sufttentaculum  tali  and  the  internal 
matlcolus.  (Fig.  11.5.)  Sequel,  serious  loss  of  functional  power, 
due  to  contracture  of  the  great  toe. 

A  workman,  thirty-nine  years  of  age,  was  injured  on  August  ^, 


Fig.  115. 


1894,  by  a  stone  falling  from  the  height  of  one  story,  striking  the 
internal  malleolus  of  his  right  foot.  He  was  treated  at  home  by  the 
lodge  doctor,  lying  in  bed  for  five  weeks;  for  three  months  afterward 
he  remained  without  medical  julvice.  He  was  in  my  care  from  Feb- 
ruary 18,  1895,  until  July  17,  1H95.  Tliere  was  a  marked  growth  of 
callus  around  and  below  the  internal  malleolus,  and  the  great  toe  was 
so  much  flexed  as  to  make  the  end  touch  the  ground.  The  patient's 
condition  has  gi'adually  grown  worse,  and  he  is  now  unable  to  tread 


FRACTURES  OF  THE  OS  C ALOIS.  491 

on  the  whole  sole  of  the  foot.  The  other  toes  have  become  contracted 
as  well  and  the  foot  has  grown  more  and  more  deformed.  The  portion 
of  the  sole  used  in  walking  is  shown  in  the  accompanying  impression. 
(Fig.  115,  p.  490.)     Insurance  allowance,  'i'iz'A- 

These  contractures  may  very  seriously  interfere  with 
the  usefuhiess  of  the  foot.  Amputation  of  the  oifending 
toes  is  the  best  treatment ;  but  if  the  patient  objects,  a 
laced  shoe,  appro})riately  shaped  and  padded,  affords 
a  certain  amount  of  relief. 

The  fracture  leaves  the  sustentaculum  thickened,  as  is 
evidenced  by  a  prominence  below  the  internal  malleolus. 
The  posterior  process  of  the  astragalus  is  usually  fractured 
at  the  same  time,  and,  if  so,  it  is  also  thickened.  The  foot 
and  whole  extremity  aj)pear  atrophied ;  rotatory  move- 
ments, including  inyersion  and  eversion,  are  abolished, 
and  flexion  and  extension  at  the  ankle-joint  are  restricted. 

Bony  union  between  the  os  calcis  and  astragalus  takes 
place  regularly  after  fracture  of  the  sustentaculum,  as 
well  as  after  compression-fractures  of  the  os  calcis ;  and, 
in  addition,  the  ligaments  connecting  the  bones — the  inter- 
osseous ligament  in  the  interosseous  groove,  for  instance — 
may  undergo  ossification. 

Tiie  insurance  allowance  in  severe  cases  amounts  to 
from  30^  to  50/^,  or  more;  in  light  cases,  from  15^  to 

Fracture  of  tiie  internal  tul)ercle  on  the  inferior  sur- 
face of  the  OS  calcis  is  a  very  interesting  lesion,  both  from 
an  etiologic  and  a  functional  standpoint.  The  tubercle  is 
pulled  forward  by  the  strong  plantar  muscles  and  the 
tense  ligaments  which  are  attached  to  it,  appearing  at  the 
middle  of  the  under  surface  of  the  bone  as  a  rounded, 
thick,  bony  ])rominence,  making  walking  very  painful  and 
difficult. 

As  early  as  1895  I  called  attention  to  these  fractures  at  the  Conven- 
tion of  Scientists  at  Llibeok.  Thiem  at  that  time  denied  their  occur- 
rence. Affirmative  proofs  were  subsequently  furnished  by  Ehret  in 
an  article  published  in  the  "  Archiv  fiir  Unfallheilkunde,"  volume  I. 
One  such  aise  has  occurred  in  my  practice. 


492 


DISEASES  CAUSED  BY  ACCIDENTS. 


Case  of  fracture  of  the  internal  tuhercJe  of  the  os  calcis,  consequent  upon 
a  fill,  leadin;/  to  sliyht  functional  (lisabiliti/. 

The  thickened  tubercle  is  shown  in  the  accompanying  illustration. 
The  condition  is  most  noticeable  with  the  feet  placed  parallel,  as  in 
figure  116.  The  tubercle  was  carried  for\\ard  by  the  plantar  muscles 
after  its  separation.     Insurance  allowance  since  August,  1898,  20%. 

It  is  unuecessary  to  speak  further  of  the  symptoms  of 
the  lesion,  as  they  are  essentially  similar  to  those  refen-ed 
to  in  connection  with  the  transverse  fractures  of  the  bone 
and  the  subsequent  thickening  of  its  lower  surface. 

Separation  of  the  tubercle  on  the  external  surface  of 
the  OS  calcis  may  accompany  fracture  of  the  body,  or,  in 
very  rare   cases,  may  occur  alone 
as  a  result  of  direct  violence.    The 
development   of    the    tubercle    is 
very  much  an  individual  matter ; 
it    is    entirely    lacking    in    some 
cases,  while   in   others  it   forms  a 
marked    prominence.      Sometimes 
there  are  two  tubercles,  and  Hyrtl 
has    even    observed    three.      The 
tubercle  most  constantly  present  is 
the    larger    one,    lying   below    the 
external    malleolus ;     the    tendon 
of   the    ]ieroneus   longus 
passes   down    behind    it, 
and  it  is  conceivable  that 
it     might     pull    off    the 
tubercle,     if    the     latter 
^'s-  116.  were    of  large    size  and 

the  foot  were  very  for- 
cibly su])inated.  It  is,  however,  out  of  the  question  for  the 
tubercle  into  which  the  calcaueofibular  division  of  the  ex- 
ternal lateral  ligament  is  inserted  to  be  separated  by  traction 
on  the  part  of  the  latter.  I  liave  never  seen  a  case  of 
indirect  fracture  of  this  tubercle  myself,  although  I  have 
known  it  to  be  broken  off  by  direct  violence — in  one  case 
by  a  blow  from  a  falling  stone,  and  in  another,  by  falling 


Fig.  117. 


494  DISEASES   CAUSED  BY  ACCIDENTS. 

and  striking  the  outer  side  of  the  foot  on  a  sharp-edged 
stone.  In  a  case  in  which  the  tendons  of  the  peronei  had 
become  involved  in  the  calhis  there  was  spasm  of  the  an- 
tagonistic muscles  of  the  leg,  causing  a  talipes  varus  and 
making  the  foot  almost  useless. 

The  outcome  is  more  favorable  when  the  peronei  form 
for  themselves  a  groove  in  the  callus  in  which  they  can 
glide. 

A  very  unusual  accident  is  cited  below,  with  an  illus- 
tration (Fig.  118),  in  which  the  os  calcis  was  fractured 
by  a  stroke  of  lightning. 

Ca.'ie  of  spontaneous  fractitre  of  the  os  calcis  {compression-frncture). 
Predisposin<>;  cause,  tuberculosis  of  the  os  calcis;  exciting  cause,  un- 
known.     (Fig.  117,  p.  493.) 

A  workman,  thirty-nine  years  of  age,  while  carrying  a  load  of 
stones,  suddenly  felt  a  pain  in  the  right  foot.  He  also  noticed  that  the 
foot  appeared  swollen.  He  began  medical  treatment  and  applied  for 
insurance  allowance.  I  took  a  skiagraph  of  the  foot  on  July  7,  1897. 
A  diagnosis  was  thereujjon  made  of  tuberculosis.  The  patient  Avas 
small,  delicate,  and  poorly  nourished.  The  lungs  were  normal.  At 
the  time  of  my  examination  the  f<Jot  was  reddened  and  greatly 
swollen;  subsei^uently  the  swelling  diminislied  somewhat.  Insurance 
allowance  was  refused,  as  there  was  no  proof  of  the  occurrence  of  an 
accident. 

Figure  118,  page  495,  shows  the  very  unusual  case  of  a  fracture  of 
the  OS  calcis  caused  by  a  stroke  of  lightning.  The  patient,  when 
eighteen  years  of  age,  was  struck  when  standing  at  a  window;  the 
bolt  entered  the  right  side  of  the  chest,  throwing  liim  to  the  floor,  and 
is  said  to  have  passed  out  at  the  right  heel  (the  scar  on  the  right  side 
of  the  chest  is  still  visible).  The  skiagraph  shows  the  peculiar  jagged 
deformity  of  the  bone.  The  patient  suffered  from  su])puration  of  the 
bone  for  nearly  a  year  and  a  half,  during  which  time  splinters  were 
continually  l)eing  thrown  off.  He  gradually  regained  strength,  and 
was  able  later  on  to  do  the  full  work  of  a  hod-carrier. 


Dislocation  of  the  Scaphoid, 

(My  Cases  Include  I]ighteen  of  Dislocation-fracture  or  ►Subluxation  of 
the  .Scaphoid.) 

Occurring  separately,  this  is  a  rare  form  of  injury. 

Dislocation-fractures  are  met  with  less  infrequently. 
Subluxations  are  seen  comparatively  often,  the  bone  being, 
as  a  rule,  displaced  downward  or  inward. 


496  DISEASES  CAUSED  BY  ACCIDENTS. 

The  lesion  may  be  caused  by  a  misstep  when  carrying 
a  heavy  load,  by  an  awkward  jump,  by  turning  the  ankle 
inward,  or  it  may  occur  in  consequence  of  a  heavy  object 
falling  on  the  foot,  or  some  similar  accident.  An  exami- 
nation by  the  X-rays  will  show  the  disphicement  at  the 
astragaloscaphoid  joint  very  clearly.  Apart  from  this,  the 
symptoms  consist  of  eversion  of  the  foot,  of  swelling  ex- 
tending^ from  the  internal  malleolus  to  bevond  the  first 
cuneiform  bone,  and  of  marked  projection  of  the  tubercle 
of  the  scaphoid.  The  inner  arch  of  the  foot  lies  nearer 
the  ground  than  on  the  normal  foot,  and  the  outer  border 
may  be  so  much  raised  that  it  does  not  touch  the  ground 
in  walking.  The  foot  is  painful  and  the  muscles  are 
atrophied. 

The  pain  may  be  severe  and  very  persistent ;  it  can 
be  somewliat  relieved  by  means  of  a  laced  shoe  padded 
as  for  flat-foot,  which  aids  also  in  overcoming  the  de- 
formity. 

Insurance  allowance,  from  25  ^y  to  ?i-j^^. 

Fracture  of  the  Scaphoid. 

The  lesion  occurs  as  the  result  of  direct  viokuice,  as 
Avlien  tlie  foot  is  crushed  by  a  heavy  weight,  or  of  indirect 
violence,  as  in  wrenching  the  foot  loose  wdien  it  is  caught 
fast.  In  tlie  latter  case  the  fracture  is  not  infrequently 
connninuted,  and  accompanied  by  more  or  less  displace- 
ment of  the  bone  upward  or  inward. 

The  injury  is  subse({uently  manifested  externally  by 
swelling  of  the  foot,  extending  from  the  ankle-joint  to  the 
anterior  portion  of  the  first  metatarsal  bone.  As  a  rule, 
the  head  of  the  astragalus  and  the  three  cimeiform  bones 
are  more  or  less  involved  in  the  injury.  Patients  com- 
plain of  pain  on  standing  and  of  an  inability  to  carry 
heavy  loads.  The  foot  can  not  be  inverted  or  everted. 
In  cases  of  fracture  due  to  direct  violence  the  adjacent 
bones  are  usually  involved  as  well  ;  the  arch  of  the  foot 
sinks  down  and  flat-foot  is  frequently  developed.     The 


Fig.  119. 


498  DISEASES  CAUSED  BY  ACCIDENTS. 

thickened  bones  can  in  many  cases  be  felt  through  the 
sole. 

Figure  119,  page  497,  and  figure  120,  page  499,  illustrate  the  case 
of  a  hod-carrier,  thirty-one  years  of  age.  On  March  IH,  1895, 
when  mounting  a  ladder  with  a  load  of  Ijricks,  his  wooden  shoe  fell 
from  his  right  foot.  In  order  not  to  endanger  the  man  behind  him, 
he  was  obliged  to  moimt  the  remaining  five  rungs  of  the  ladder  with 
his  foot  unprotected.  Each  step  caused  intense  pain  in  the  foot,  which 
became  greatly  swollen,  c^iusing  him  to  discontinue  work.  He  was 
treated  at  home  with  bandages  and  ointments  until  April  20th.  Then 
he  entered  a  hospital,  where,  however,  he  remained  only  for  six  days. 
While  there  he  Avas  treated  with  massage.  I  first  examined  him  on 
June  4,  1895,  and  had  him  under  treatment  until  October  7,  1895. 
The  foot  was  greatly  swollen,  esijecially  just  in  front  of  the  malleoli. 
There  was  a  bony  protrusion  in  front  of  and  ])artly  iinderneath  the 
internal  malleolus,  a  similar  condition,  only  more  marked,  existing  in 
front  of  the  external  malleolus.  A  rather  hard  mass  could  also  be  felt 
at  the  inner  border  of  the  inner  arch  of  the  foot.  When  discharged, 
the  patient  was  granted  35^  insurance  allowance.  He  returned  for 
further  treatment  on  February  26,  1896,  on  account  of  an  increase  of 
the  symptoms,  being  discharged  for  a  second  time  on  No\ember  213, 
1896.  Diagnosis  was  made  of  fractures  of  the  greater  ]H-ocess  of  the  os 
calcis,  the  neck  of  the  astragalus,  the  scaphoid,  and  the  tubercle  on 
the  posterior  surface  of  the  astragalus.  The  skiagraph  ( Fig.  119,  p. 
497)  shows  the  fracture  of  the  scaphoid  and  the  partial  splintering  of 
the  ciiueiform  bone  very  distinctly.  The  line  of  fractin-e  on  the  neck 
of  the  astragalus  can  also  be  traced ;  that  of  the  upi)er  border  of  the 
greater  process  of  the  os  calcis  is  less  distinctly  visible.  The  posterior 
tubercle  of  the  astragalus  is  seen  to  be  displaced  in  the  direction  of  the 
OS  calcis.  The  displacement  of  the  fractured  scaphoid  is  plainly  shown 
in  figure  120.  The  patient  is  now  able  to  A\alk  fairly  well,  and  the 
symptoms  have  considerably  diminished. 

Direct  fractures  of  th(»  three  cuneiform  bones  are  caused 
in  the  same  manner  as  fractures  of  the  scajihoid,  and  as 
the  symptoms  are  also  identical,  it  Avill  be  lumecessary  to 
repeat  them. 

Case  of  mhluxation  of  the  first  cuneiform  hone.  (Fig.  121,  p.  500.) 
A  hod-carrier,  thirty-six  years  of  age,  fell  from  a  liwlder  on  May  1, 
1896,  striking  on  the  left  foot.  He  was  already  a  sufferer  from  flat- 
foot.  He  was  treated  in  the  hospital,  wearing  a  plaster  cast  for 
twenty-four  days.  The  course  of  after-treatment  lasted  until  January 
25,  1897,  when  he  was  discharged  with  an  insurance  allowance  of  25^. 
The  illustration  distinctly  shows  a  convex  tumor  on  the  dorsum  of  the 
foot  and  a  similar  but  le.ss  well-marked  protrusion  on  the  plantar  sur- 
face.    The  former  represents  the  upward  displacement  of  the  base  of 


Fig.  120. 


500 


DISEASES   CAUSED  BY  ACCIDENTS. 


the  first  metatarsal  bone;  the  latter,  the  downward  displacement  of 
the  first  cuneiform  bone. 

Case,  of  subluxation  of  the  scaphoid  [downward  displacrninit).  (Fig. 
122,  p.  501.) 

A  workman,  thirty-five  years  of  age,  Avas  injured  on  April  23,  1887, 
by  a  falling  beam,  which  crushed  his  right  foot.  He  Avas  .at  first 
treated  at  home ;  later  on,  in  myelinic.  It  was  difiicult  for  him  at 
first  to  bear  his  weight  on  the  injured  foot.  He  improved  greatly 
under  treatment,  however,  and  was  discharged  on  December  20,  1887, 
with  an  insiirance  allowance  of  25%,  which  was  reduced  to  10%  in 
July,  1889.  In  the  beginning  of  1890  he  fractured  the  left  aukle, 
after  which  the  right  foot  became  more  painful.  Full  c<apacity  for 
self-sup])ort  was  recovered  by  1897.  The  skiagraph  shows  the  down- 
ward (lisi)laccment  of  the  scajjhoid,  partly  involving  the  first  cunei- 
form l)one  as  well,  and  the  up\\ard  displacement  of  the  first  cuneiform 
and  first  metatarsal  bones  at  the  point  of  their  articulation. 


Tlie  cuneiform  bones  arc  very  seldom  completely  frac- 
tured by  indirect  violence  ;  overflexion,  however,  Avlien 
the  foot  is  caught  fast,  sometimes  causes  small  splinters 
to  be  chipped  off.  The  after-symptoms  are  similar  to 
those  of  fracture  of  the  bases  of  the  first  three  metatarsal 
bones. 

Indirect  fractures  of  the  bones  of  the  inner  arch,  involv- 
ing both  the  scaphoid  and  the  cuneiform  bones,  occasion- 
ally occur  as  the  result  of  carrying  extraordinarily  heavy 
loads. 


Fig.  122. 


502  DISEASES  CAUSED  BY  ACCIDENTS. 

The   chief  aim  of  after-trcatiiu'iit  of  all    the  fractures 

of  the  inner  arch  is  to  furnish  the   patient  Avith  the   best 

possible  support   in   standing-  and  walking.      A  properly 
shaped  and  padded  shoe  is  of  prime  importance,  although 

massage,  local   baths,  and  gymnastic   exercises  will   also 
be  found  beneficial. 


Dislocation  of  the  Cuneiform  Bones. 

(My  Material  Includes  I'^orty-two  Cases  of  J^islocations,  P'ractiires,  and 
Dislocation-fractures  of  These  Bones. ) 

The  first  cuneiform  bone  is  the  one  most  subject  to 
dislocation.  Either  of  the  others  may,  however,  suffer 
separately,  or  all  three  may  be  dislocated  at  once.  The 
majority  of  cases  occur  in  connection  with  fracture,  the 
fragments  being  then  displaced  U})ward  or  downward,  or, 
in  the  case  of  the  first   cuneiform   bone,  possibly  inward. 

Subluxation  occurs  mor(>  frequently  than  complete  dis- 
location ;  splinters  are  apt  to  be  chijiped  off  the  adjacent 
bones  at  the  same  time. 

The  lesion  is  caused  by  direct  violence  when  heavy 
objects  fall  on  the  foot,  displacing  the  bone  downward. 
Indirectly,  it  occurs  when  a  person  catches  the  toes  in  an 
oj)ening  and  falls  over  backward,  thus  forcibly  bending 
the  foot. 

Subluxation,  too,  is  most  often  met  with  in  the  first 
cuneiform  bone.  In  cases  of  downward  displacement  our 
attention  is  first  attracted  to  the  lesion  by  the  prominence 
of  the  scaphoid  or  the  base  of  the  first  metatarsal  bone 
on  the  back  of  the  foot ;  the  first  cuneiform  can  be  felt 
to  jn'oject  on  the  ])lantar  surfac(>,  and  is  usually  sensitive 
to  pressure.  The  inner  bordei-  of  the  foot  remains 
swollen  for  some  time,  and  if  the  foot  is  only  slightly 
arched,  the  patient  avoids  stej)ping  on  it,  and  walks  on 
the  outer  part  of  the  sole.  If  the  arch  is  a  high  one, 
tlusre  is  no  abnormality  of  gait,  but  standing  for  any 
length  of  time  or  carrying  heavy  weights  becomes  painful. 


DISLOCATION  OF  THE  CUBOID.  503 

The  toes  remain  stiif  for  a  time,  especially  the  great  toe, 
and  the  plantar  muscles  are  temporarily  atrophied. 

Considerable  relief  is  afibrded  the  patient  by  a  suitable 
shoe. 

Insurance  allowance,  from  15^  to  25^,  or  more. 

In  cases  of  upward  dis[)lacement  the  symptoms  are 
similar,  except  that  the  dorsum  of  the  foot  appears  ab- 
normally prominent  and  no  projection  is  felt  on  the  sole. 

Dislocation  of  the  Cuboid. 

(The  Cuboid  Was  Injured  in  Twentj'-two  of  My  Cases.) 

Complete  dislocation  of  the  cuboid  is  a  very  unusual 
lesion. 

Subluxation  occurs  more  often  ;  it  is  observed  when  the 
back  of  the  foot  is  crushed,  especially  when  it  is  com- 
pressed between  two  objects,  and  violent  efforts  are  made 
to  extricate  it.  When  the  bone  is  displaced  upward,  it 
appears  as  a  distinct  prominence  on  the  outer  border  of 
the  foot.  The  belly  of  the  extensor  comnumis  brevis 
stands  out  more  distinctly  than  on  the  uninjured  foot,  and 
the  outer  toes  are  somewhat  extended  by  the  tension  of 
their  respective  tendons.  There  may  be  talipes  varus, 
the  patient  walking  on  the  outer  border  of  the  foot,  but 
in  some  cases  we  find  talipes  valgus.  Downward  dis- 
placement leaves  a  depression  on  the  outer  side  of  the 
back  of  the  foot,  and  the  foot  is  held  everted. 

Patients  usually  complain  of  pain  on  the  outer  part  of 
the  back  of  the  foot,  and  along  its  outer  border,  running 
across  the  sole  to  the  point  of  insertion  of  the  ])eroneus 
longus.  A  laced  shoe,  appropriately  padded,  will  some- 
what relieve  the  pain  and  discomfort  experienced  on  stand- 
ing and  walking,  wliich  are  also  favorably  affected  by 
massage  and  medicomechanical  exercises  systematically 
carried  out.  Operative  interference  is  sometimes  indi- 
cated. The  rule  for  all  except  the  most  severe  cases  is  that 
the  symptoms  entirely  disappear  by  the  end  of  six  months. 

Insurance  allowance,  from  20^  to  33^^. 


504  DISEASES  CAUSED  BY  ACCIDENTS. 

The  dislocation-fractures  of  the  cuboid  are  usually  mul- 
tiple or  conuiiiuutcd,  occurriuo;  when  the  foot  is  badly 
crushed.  The  fragments  are  likely  to  be  displaced  (piite 
irregularly. 

Fractures  of  the  Cuboid. 

Direct  violence  to  the  foot  in  cases  of  caving-in  accidents 
or  when  the  foot  is  struck  by  heavy  falling  objects,  or  oc- 
curring in  the  form  of  a  fall  or  leap  from  a  height,  is  the 
usual  cause  of  these  fractures.  They  generally  involve  the 
adjacent  bones  ;  the  tubercle  on  the  base  of  the  fifth  meta- 
tarsal bone  is  most  likely  to  suffer ;  the  greater  process 
of  the  OS  calcis,  however,  and  the  bases  of  the  fourth  and 
fifth  metatarsals  are  usually  fractured  also. 

The  subse({uent  thickening  of  the  bone  is  most  percep- 
tible through  the  sole  of  the  foot,  which  is  held  everted 
in  walking,  partly  because  of  the  pain  caused  by  pressure, 
partly  because  of  the  j)r()minence  of  the  bone  on  the  outer 
border.  The  strain  put  on  the  tendon  of  the  peroneus 
longus  by  the  maintenance  of  this  position  is  likely  to 
cause  an  irritation  or  inflammation  of  the  latter.  In  some 
cases,  however,  this  is  to  be  attributed  to  direct  injury 
from  pressure  of  the  callus.  Genu  valgum  is  frequently 
observed. 

The  patient  should  wear  a  shoe  so  made  as  to  relieve 
the  cuboid  from  pressure. 

Dislocation  and  Subluxation  of  the  Metatarsal  Bones. 

Partial  dislocation  of  the  metatarsal  bones  at  their  basal 
extremities  occurs  under  the  same  conditions  as  do  similar 
lesions  of  the  cuboid,  and  gives  rise  to  almost  identical 
symptoms.  The  disj)lacement  may  be  upward  or  down- 
ward. Uj)ward  displacement  of  the  bases  of  all  five 
metatarsal  bones  ])rodu('es  talij)(^s  cavus,  shortening  the 
foot.  Displacement  downward  brings  about  the  opposite 
condition  of  flat-foot.  If  the  head  of  one  or  more  of  the 
metatarsal  bones  is  dislocated  downward,  its  base  may  be 


DISLOCATIONS  OF  THE  METATARSUS.  505 

proportionately  displaced  uj)\vard.  In  such  a  case  the 
patient  always  complains  of  pain  on  bearing  his  weight 
on  the  foot,  and  tries  to  avoid  stepping  on  the  painful 
part.  If  the  fourth  metatarsals  are  involved,  therefore, 
the  foot  will  be  held  everted  in  walking.  The  position 
of  the  heads  is  indicated  by  a  rounded  eminence  on  the 
sole  of  the  foot,  and  the  affected  toes  are  usually  fixed  in 
more  or  less  pronounced  extension.  The  gait  is  affected 
in  proportion  to  the  deformity.  A  laced  shoe,  padded  to 
allow  for  the  projection  of  the  dislocated  bones  on  the 
tread,  is  a  very  necessary  requirement. 

The  average  insurance  allowance  is  20  ^ . 

The  symptoms  which  develop  when  the  heads  of  the 
metatarsal  bones  are  displaced  u})ward  have  an  even  more 
unfavorable  influence  on  the  ability  of  the  patient  to  walk 
or  stand.      The  affected  toes  are  usually  flexed. 

Lateral  dislocation  of  individual  metatarsal  bones  is 
possible  only  in  the  case  of  the  first  and  fifth,  and  occurs, 
doubtless,  in  all  cases  in  connection  with  fracture  of  their 
bases.  Unless  the  dislocation  or  subluxation  is  completely 
reduced,  the  foot  becomes  abnormally  broad,  or  flat-foot 
may  develop.  In  case  of  inward  dislocation  of  the 
first  metatarsal  bone  tlie  foot  is  narrowed  in  the  middle 
of  its  transverse  arch.  The  joint  between  the  first  meta- 
tarsal and  the  first  cuneiform  becomes  enlarged,  and  per- 
haps inflamed. 

AVe  occasionally  meet  with  lateral  dislocation  of  the 
metatarsal  bones  as  a  whole  at  the  tarsometatarsal  joints 
in  connection  with  fracture  of  the  latter.  The  metatarsal 
bones  usually  remain  displaced  either  outward  or  inward, 
and  flat-foot  or  club-foot  is  likely  to  develop.  Walking 
is  very  difficult  for  a  time,  and  a  well  fitting  and  properly 
padded  laced  shoe  is  an  important  factor  in  restoring  the 
usefulness  of  the  foot. 

Insurance  allowance,  from  25^  to  33^^. 


506  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  39. 

Fig.  1. — A  workman,  thirty-eight  years  of  age,  sustained  a  compound 
fracture  of  tlie  bones  of  all  five  toes  of  the  right  foot  on  November  1, 
1897,  caused  by  tliree  Ijeams  falling  upon  the  l)ack  of  the  foot.  The 
first  t\\o  toes  had  to  be  amputated.  The  contracture  of  the  re- 
maining three  toes  and  the  extensive  scars  on  the  back  of  the  foot  are 
shown  in  the  illustration.  The  skin  appears  cyanotic.  The  skiagraph 
(Fig.  124,  p.  508)  sho^^•s  the  fractures  of  the  metatarsal  bones  and  the 
position  in  which  the  heads  of  these  bones  became  consolidated.  The 
extreme  degree  to  which  the  foot  was  shortened  is  shown  in  the  sole- 
impressions  of  figure  123,  page  507.     Insurance  allowance,  33^%. 

Fig.  2. — This  illustrates  the  case  of  a  workman,  twenty-eight  years 
of  age,  the  great  toe  of  whose  left  foot  was  fractured  on  November 
18,  1897,  by  the  fall  of  an  iron  bolt.  The  fracture  was  compound. 
The  line  of  fracture  is  visilde  in  the  accompanying  skiagraph.  (Fig. 
125,  p.  509.)  The  scar  over  the  metatarsophalangeal  joint  of  the 
great  toe,  the  glossy  skin  of  the  part,  and  the  I'etraction  of  the  scar, 
throwing  the  skin  into  radiating  folds,  are  shown  in  figure  2.  It  was 
at  first  ^•ery  difficult  for  the  patient  to  place  the  inner  border  of  the 
foot  to  the  ground,  on  account  of  the  protrusion  of  the  ball  of  the 
great  toe.  The  appearance  of  the  foot  at  the  time  of  the  patient's  dis- 
charge, on  Augiist  6,  1898,  was  identical  with  this  illustration,  but  the 
gait  was  excellent.  Insurance  allowance,  33^  ^ ,  at  first,  advanced  by 
the  court  to  50%  ;  in  February,  1899,  it  was  reduced  to  20%. 


Fractures  of  the  Metatarsal  Bones. 

(112  Cases.) 

These  fractures  are  of  fre(jiient  occurrence  in  the  build- 
ing and  allied  trades,  in  which  the  foot  is  exposed  to 
injury  i'vom  falling  objects.  They  are  usually  of  the 
direct  variety,  and  often  pass  unrecognized  under  the 
diagnosis  of  "  crushed  foot."  Indirect  fractures  are 
caused  by  turning  the  ankle,  especially  when  a  workman, 
in  carrying  a  heavy  load,  catches  the  foot  in  something, 
in  Avhich  case  the  fourth  and  fifth  metatarsals  are  most 
likely  to  be  the  seat  of  fracture.  The  second  and  third 
are  less  frequently  involved.  Sometimes  the  fracture 
occurs  as  the  ivsiilt  of  putting  tiie  foot  down  very  heavily 
to  mark  time  in  marching. 

Direct  fractures  of  the  first  three  metatarsal  bones  lead 
to  the  development  of  flat-foot.     This  is  the  necessary 


CO 


I 


FRACTURES  OF  THE  METATARSUS. 


507 


consequence  of  the  lesion,  caused,  as  it  is,  bv  the  impact 
of  a  heavy  object  on  the  posterior  extremity  of  the  bones, 
since  these  do  not  rest  on  the  ground,  l)ut  rely  for  their 
support  on  the  various  ligaments  which  maintain  the  shape 
of  the  arch. 

Fi'actures  of  the  first  metatarsal  bone  are  likely  to  lead 
to  deformities  which  seriously  interfere  with  the  usefulness 


Fig.  123. 

of  the  foot.  This  is  especially  the  case  when  one  or  l)otli 
fragments  are  displaced  downward.  Consolidation  is  ac- 
companied by  a  well-marked  growth  of  callus,  which 
adds  to  tiie  deformity — the  more  so  tiie  nearer  the  fracture 
lies  to  the  so-callo<l  ball  of  the  great  toe.  The  sesamoid 
bones  at  the  anterior  extremity  of  the  first  metatarsal  bone 


Fig.  124. 


Fig.  125. 


510  DISEASES  CAUSED  BY  ACCIDENTS. 

are  frequently  broken  or  dislocated  at  the  same  time  by 
direct  violence,  making  walking  doubly  painful  for  a  long 
period.  In  examining  the  injured  foot  we  find  the  part  of 
the  sole  corresponding  to  the  anterior  portion  of  the  first 
metatarsal  bone  much  more  prominent  than  on  the  normal 
foot.  (See  Plate  39,  Fig.  2.)  The  prominent  portion  is 
hard  and  is  sensitive  to  pressure.  The  effort  of  the 
patient  to  avoid  pain  causes  him  to  walk  on  the  outer  part 
of  the  foot,  which,  if  not  treated  in  season,  may  lead  to 
a  paralysis  of  habit. 

In  other  cases  the  fragments  are  displaced  inward, 
greatly  increasing  the  anterior  transverse  diameter  of  the 
foot.  Hallux  valgus  or  varus  occurs  as  a  secondary  result 
of  the  displacement  of  the  anterior  fragment. 

The  upward  dis})lacement  of  one  of  the  fragments 
shortens  the  foot,  and  is  of  practical  importance,  since  it 
obliges  the  patient  to  wear  a  special  shoe  in  order  to  pro- 
tect the  callus  on  the  back  of  the  foot  from  pressure. 

Case  of  compound  fracture  of  (he  first  metatarsal  hone,  with  ennseejuent 
slifiht  spreadi)Kj  of  the  toes.      (Fiji;-  l'-^6,  p.  511.) 

The  skiagraph  shows  the  condition  as  it  existed  shortly  ))efore  the 
patient's  diseliarge  from  my  hospital.  He  was  nineteen  years  of  age; 
his  left  foot  was  injnred  on  March  12,  1897,  by  a  signl)oard  falling 
upon  it.  Suppuration  set  in  in  the  niotatarsoplialangeal  joint  of  the 
great  toe,  which  was  opened  and  drained  in  the  hospital.  He  was  dis- 
charged from  after-treatment  on  October  1(5,  1S97,  with  an  insurance 
allowance  of  25%.  He  walked  on  the  outer  edge  of  the  foot,  being 
])revented  from  treading  on  the  ball  by  the  scjir  on  the  under  surface 
of  the  great  toe. 

The  skiagraph  (Fig.  127,  p.  512)  illustrates  a  case  of  fracture  of  the 
posterior  extremity  of  the  first  metatarsal  bone,  of  the  base  of  the 
second  metatarsjil,  and  of  a  ])artial  transverse  fracture  of  tlu^  anterior 
portion  of  the  third  metatarsid  bone.  The  back  t)f  the  left  foot  was 
crushed  at  the  sjime  time  by  the  iron  beam  which  Ciiused  the  injury, 
and  the  patient,  a  man  forty-fovn'  years  of  age,  was  sent  to  me  with  a 
diagnosis  of  crushed  foot.  He  \\as  under  treatment  from  October  1, 
1894,  the  date  of  the  injury,  until  May  9,  1899. 

When  discharged,  he  recu-ived  an  insurance  allowance  of  30%,  re- 
duced in  May,  1899,  to  10%.  In  addition  to  the  flat-footedness  which 
was  consequent  upon  the  injury,  the  first  and  second  metatai-siil  bones 
were  thickened  and  the  anterior  portion  of  the  third  metatarsal  bone 
was  also  slightly  thickened.  This  condition  caused  difficulty  in  walk- 
ing at  first;  subsequently,  the  thickening  became  much  less  marked, 
and  the  gait  improved  in  proportion. 


Fig.  126. 


FiL'.  127. 


Fig.  128. 


514  DISEASES  CA  USED  BY  A CCI DENTS. 

Case  of  reunited  frocturc  of  the  lic<t(h  of  the  first  and  fifth  metatarsal 
hones  accompanied  bi/  sulilu.vationof  the  second,  third,  and  fourth  metatar- 
sal bones  upward,  and  bij  inward  displacement  of  the  fifth.  (Fig.  1'28, 
p.  513. )     The  accident  caiisiiif;  tiiese  injuries  was  a  eavinj^-in. 

Tlie  patient  was  at  first  treated  in  a  hospital,  entering  my  hos- 
pital for  a  course  of  after-treatment  on  Septem))er  9,  1897.  At 
first  he  walked  Avith  difficulty,  using  a  crutch  and  a  cane.  He  was 
discharged  on  Novemljer  27,  1897,  with  an  insurance  allowance  of 
33j%.  The  foot  presented  a  talipes  varus,  and  the  dorsum  was  dis- 
tinctly convex.  Flat-foot  had  previously  existed.  The  skiagraph 
shows  the  fractures  and  the  displacement  of  the  metatarsal  bones  very 
distinctly. 

Case  of  fracture  of  the  head  of  the  fifth  mctedarsal  bone,  with  upward 
displacement  of  the  little  toe  and  the  bases  of  the  .second,  third,  and  fourth 
metatarsal  bones.      ( Fig.  129,  p.  'Art. ) 

The  patient  in  this  case  was  a  ANorkman,  fifty-one  years  of  age.  On 
March  8,  189ft,  a  building-stone  fell  on  the  little  toe  of  the  left  foot, 
causing  the  ankle  to  turn  outward.  He  was  under  treatment  until 
November  19,  1898.  The  displacement  of  the  several  bones  is  clearly 
shown  in  the  skiagraph.  Insurance  allowance  at  the  time  of  dis- 
charge, 20%. 

Case  of  fracture  of  the  second  and  third  mctedarsal  bones  with  displace- 
ment of  the  metatarsed  bones  and  the  first  and  second  cuneiform  bones. 
(Fig.  130,  p.  516. ) 

In  this  case  the  injury  was  caused  by  a  signboard  falling  on  the 
right  foot.  The  patient,  ■who  was  a  painter,  twenty-eight  years  of  age, 
was  under  treatment  for  five  weeks;  in  the  sixth  week  he  began  to 
work  again,  and  at  the  end  of  a  few  weeks  more  had  completely  re- 
covered. 

The  displacement  of  the  bones  is  well  shown  in  the  skiagraph. 

Case  of  fracture  of  the  third,  fourth,  and  fifth  metatarsal  bones.  (Fig. 
131,  p.  517.) 

A  workman,  twenty-sLx  years  of  age,  was  hit  on  the  left  foot  with 
a  clul)  on  Septemlier  7,  1897.  He  was  treated  at  home  for  fourteen 
weeks,  at  first  with  ice-compresses  and  l)y  rest  in  bed;  later  on,  by 
mas.sage.  He  then  entered  upon  a  course  of  treatment  in  my  clinic, 
which  was  continued  until  Ajnil  25,  lft9ft.  The  skiagraph  was  taken 
at  the  time  of  his  discharge.  The  back  of  his  foot  ])reseiit((l  a  convex 
deformity  and  the  foot  was  slightly  broadened  across  the  middle.  At 
first  lie  was  very  lame;  his  gait  afterward  became  perfectly  normal. 
Insurance  allowance,  25%. 

If  the  fracture  involves  the  anterior  ])ortion  of  the 
metatarsal  bones,  the  heads  of  the  respective  hones  may 
become  entirely  displaced  downward,  to  the  side,  or,  far 
less  frequently,  upward.  Downward  displacement  inter- 
feres directly  with  trcadiniron  the  foot  ;  lateral  dislocation 
has  a  similar  vmfavorable  effect,  although  indirectly,  by 


Fie.  129. 


Fig.  130. 


Fig.  131. 


518  DISEASES  CAUSED  BY  ACCIDENTS. 

causing  [)ressure  on  the  heads  of  the  adjacent  hones. 
Prominent  points  corresponding  to  the  (hsphiced  frag- 
ments can  be  seen  on  the  back  of  the  foot,  and  are  even 
more  distinctly  perceptible  on  palpation. 

In  some  cases  we  tind  these  fractnres  to  be  incomplete  ; 
the  bones  are  bent  or  broken  only  part  way  across.  They 
permit,  nevertheless,  of  snfficient  lateral  displacement  of 
the  heads  of  the  injured  bones  to  cause  pressure,  which 
gives  rise  to  pain  in  walking. 

The  joints  are  affected  in  proportion  to  their  })roximity 
to  the  fracture.  The  pain  in  walking,  of  which  the  patients 
complain,  may  be  due  to  ankylosis  or  to  the  displacement 
alone.  The  displacement  at  the  tarsometatarsal  joints  is 
definitely  limited  ;  the  joints  remain  painful,  however, 
for  walkino;  and  standiuLT  for  a  considerable  len«:th  of 
time. 

The  position  of  the  toes  is  necessarily  altered  by  dis- 
placement of  the  anterior  fragments.  In  some  cases  we 
find  them  extended  ;  in  others,  they  are  displaced  back- 
ward, together  with  tlie  anterior  fragments  ;  or,  again,  they 
are  hekl  more  or  less  tightly  flexed.  If  the  line  of  frac- 
ture runs  through  th(>  heads  of  the  metatarsal  bones  into  the 
metatarsophalangeal  joints,  ankylosis  of  the  latter  is  an 
invariable  sequel.  After  fracture  of  the  fifth  metatarsal 
bone,  accompanied  by  lateral  dislocation,  the  foot  becomes 
broadened,  as  in  cases  of  fracture  of  the  first  metatarsal 
bone. 

I  have  seen  two  cases  in  which  separation  of  the 
tubercle  at  the  base  of  the  fifth  metatarsal  bone  formed  the 
sole  lesion.  One  patient  was  a  workman,  about  forty-five 
years  old,  who  had  caught  his  foot  in  a  roof-gutter,  and 
had  fallen  down  on  the  roof.  He  did  not  stop  work. 
The  other  case  occurred  in  a  tall,  heavily  built  hod- 
carrier,  who  had  fallen  from  a  ladder.  He  remained  in 
bed  for  six  weeks,  as  walking  was  painful,  but  resumed 
work  soon  afterward. 


Fig.  132. 


620  DISEASES  CAUSED  BY  ACCIDENTS. 


Traumatic  Flat=foot. 

Notwithstanding  the  tact  that  the  traumatic  develop- 
ment of  flat-foot  does  not  accord  witli  tlie  ordinary  theory 
of  origin  of  the  deformity,  it  seems  proper  to  use  this 
term  when  the  arch  of  the  foot,  in  consequence  of  trau- 
matism, becomes  so  much  lowered  as  to  allow  it  to  touch 
the  ground  in  walking. 

This  condition  is  met  with  after  fractures  involving  the 
bones  of  the  inner  arch  (os  calcis,  scaphoid,  cuneiform 
bones,  and  first  to  third  metatarsal  bones).  Traumatic 
flat-foot  gives  rise  to  the  same  painful  symptoms  as  the 
nontraumatic  variety. 

The  treatment,  besides  wearing  an  aj)propriate  shoe,  in- 
cludes massage,  baths,  etc. 

The  rate  of  insurance  allowance  is  estimated  according 
to  the  functional  disability  ;  as  a  rule,  it  amounts  to  from 
25  fo  to  33^  '/o  or  more. 

Flat-foot  (talipes  planus)  is  to  be  distinguished  from 
talipes  valgus,  which -is  a  different  deformity,  although  it 
may  represent  a  ])reliminary  stage  of  tiie  former.  The 
term  is  sometimes  loosely  applied  in  describing  a  condi- 
tion which  in  reality  is  a  valgus. 

In  old  cases  of  flat-foot,  giving  no  trouble  whatever,  a 
sprained  ankle  or  severe  contusion  may  cause  the  develop- 
ment of  all  the  acute  symptoms  of  a  recent  case  of  trau- 
matic origin,  requiring  the  same  careful  treatment  and 
entitling  the  })atient  to  the  same  insurance  allowance. 
Such  a  case  is  covered  by  the  clause  relative  to  the  exacer- 
bation of  a  chronic  disorder  in  consequence  of  an  acci- 
dent. 

The  sole-impressions  shown  in  figure  185,  page  522,  ilhistrate  the 
case  of  a  mason,  sixty-fonr  years  of  age,  who  fell  from  u  scaffolding  on 
September  IS,  181)3,  sustaining  a  typical  inversion-fracture  of  the  ankle- 
joint.  As  talipes  varus  existed  to  an  extreme  degree,  and  the  ankle 
was  completely  stiff,  an  o])eration  was  performed  in  the  hos])ital  for 
the  substitution  of  a  tali])es  \algus.  I'lie  foot  remained  in  i)laster  for 
eighteen  weeks.     At  the  time  at  which  I  examined  the  patient  only 


TBA  UMA  TIG  FLA  T-FOO  T. 


523 


the  inner  border  of  the  foot  ^\as  used  in  walking,  as  is  shown  in  the 
accompanying  impression.  (Fig.  11^7.)  The  patient  is  still  obliged 
to  use  a  cane;  the  ankle  and  leg  remain  greatly  swollen  and  the  ankle 
is  completely  ankylosed.  He  receives  100^  insurance  allowance, 
partly  in  consideration  of  his  advanced  years. 

The  sole-impressions  shown  in  figure  136,  page  522,  are  taken  from 
the  case  of  a  carpenter,  thirty -four  years  of  age,  who  leaped  from  a 
wall  one  story  high  on  November  5,  1897,  spraining  the  right  ankle. 


¥\g.  1.37. 


This  lesion  was  accompanied  by  a  dislocation  of  the  inferior  tibio- 
fil)u]ar  articulation  and  a  fracture  of  the  external  malleolus. 

When  1  examined  the  patient,  on  Decendier  l(i,  1>''!)7,  I  found  a 
marked  ease  of  tali])es  varus;  the  toes  did  not  touch  the  grotind.  The 
portion  of  the  sole  used  in  walkhig  is  shown  in  the  accom])anying  im- 
pression. (Fig.  136.)  There  was  a  slight  genu  valgum,  and  the 
muscles  of  the  foot  and  legajjpeared  atrophii'd.  The  i)atient  was  under 
treatment  until  July  29,  ls<)S,  when  he  was  discharged  with  50 '/<  in- 
surance allowance.     His  gait  had  somewhat  improved. 


524  DISEASES  CAUSED  BY  ACCIDENTS. 


PLATE  40. 

Fig.  1. — A  potter,  forty-tliree  years  of  age,  on  Septenilier  9, 
1897,  fell,  with  the  ladder  on  wliicli  he  was  standing,  a  piece  of  iron 
falling  on  his  foot  at  the  same  time.  The  contused  wound  over  the 
point  of  origin  of  the  extensor  communis  brevis  became  the  seat  of  an 
adherent  scar,  which  interfereil  with  flexion  of  the  toes  for  a  consid- 
erable length  of  time.  Insurance  allowance,  30%,  partly  on  account 
of  the  atrophy  of  the  foot;  this  was  reduced  in  June,  1899,  to  15%. 
The  patient  was  under  treatment  for  a  full  half  year. 

Fig.  2. — A  painter,  thirty-nine  years  of  age,  fell  from  a  scaffolding 
on  September  10,  1897,  sustaining  a  compound  dislocation-fracture  of 
the  astragalus.  He  was  treated  in  the  liospital,  where  a  plaster  cast 
was  applied.  A  club-foot  resulted,  and  the  leg  was  lengthened  by  the 
malposition  of  the  tibia  on  the  astragalus,  the  margins  of  the  lower 
articular  surface  of  the  former  resting  across  the  margins  of  the  trochlea 
of  the  latter.  The  ankle-joint  was  entirely  stiffened  and  the  leg  was 
greatly  atrophied.  The  illustration  shows  a  convex  prominence  be- 
tween the  leg  and  the  l)ack  of  the  foot  and  the  scar  on  the  outer  side 
of  the  ankle.  In  the  skiagraph  (Fig.  Il5r2)  is  seen  the  displacement 
at  the  ankle-joint  and  the  projection  of  the  head  of  the  astragalus. 
The  comparison  between  the  sole-impressions  taken  at  the  commence- 
ment and  at  the  end  of  the  medicomechanical  course  of  treatment  is 
very  interesting.  When  the  patient  entered  my  hospital,  on  March 
28,'lH98,  he  Avas  unable  to  stand  with  the  feet  placed  parallel,  but  was 
obliged  to  put  the  right  foot  in  front  of  the  left.  Very  little  of  the  foot 
was  used  in  walking,  as  is  shown  in  figure  133,  page  521,  in  which 
the  extreme  degree  of  talipes  varus  that  existed  can  also  be  recognized. 
When  discliarged,  on  August  (5,  1H9H,  the  varus  liad  been  overcome  to 
a  consi(leral)le  degree,  the  feet  could  be  placed  parallel,  and  the  gait 
was  strikingly  improved.     (Fig.  134,  p.  521.) 

Insurance  allowance,  75%. 


The  skiagraph  taken  at  the  time  of  his  discharge  showed  the  ex- 
ternal malleolus  to  be  entirely  disj)laced  from  the  tibia  at  the  inferior 
til)iofibular  joint;  the  anterior  extremity  of  the  os  calcis  was disjjlaced 
upward  at  the  calcaneocuboid  joint;  the  head  of  the  astragalus  was 
also  displaced  tip  ward,  and  the  tibia  was  slightly  rotated  on  the 
tnx'hlea  of  the  astragalus.  Tlic  insurance  allowance  was  reduced  in 
IMarch,  1^99,  to  30/.. 

The  sole-impressions  shown  in  figure  137,  page  523,  illustrate  the 
case  of  a  mason,  thirty-three  years  of  age,  who  stei)])ed  on  a  small 
stone  and  sprained  his  ankle  on  Decendjer  12,  189(5.  In  addition  to 
the  sprain,  there  was  a  dislocation  of  the  external  malleolus  and  a 
slight  splintering  of  the  greater  process  of  the  os  calcis. 

When  I  examined  the  patient  later  on,  there  was  marked  talipes 
varus;  the  patient  walked  entirely  on  the  outer  edge  of  his  foot, 
which,  in  addition,  presented  internally  a  concave,  and  externally  a 


TabAo. 


Fitj.l. 


"> 


FiffJ^. 


TEA  UMA  TIC  CL  UB-FOO  T. 


525 


convex,  deformity.  The  skiagraph  shoAvs  a  t^T^ica!  displacement  of  the 
ankle-joint,  niid-tarsal  joint,  and  inferior  tibiofibular  joint.  The 
part  remained  extremely  painful  for  a  long  time,  and  the  atrophy  of 
the  whole  extremity  \vas  very  persistent.  The  patient  was  discharged 
on  September  24,  1><97,  with  an  insurance  allowance  of  oOVc,  reduced 
in  April,  189S,  to  2(1%,  the  condition  of  the  foot  having  gradually  im- 
proved.    There  has  been  no  change  as  to  rate  since  that  time. 


Traumatic  Club=foot. 

This  develops  as  a  setjuel  of  fracture  or  dislocation  of  the  astragalus 
(outward  dislocation),  fracture  of  the  os  calcis  and  astragalus  both,  or 
fracture  of  the  metatarsus.  The 
most  striking  deformities  are  seen 
after  fractures  of  the  os  calcis  and 
astragalus  or  after  disloc^ation-frac- 
tures  of  the  latter.  ( See  Plate  40, 
Fig.  2.  ) 

True  club-foot  must  be  dis- 
tinguished from  talipes  varus, 
which  may  e.xist  without  constitut- 
ing a  club-foot. 

Functional  disability  is  ustially 
extreme  in  cases  of  traumatic  chd> 
foot,  and  a  long  couise  of  treatment 
is  required.  Insurance  allowance, 
from  33A%  to  50%. 

The  suljject  of  the  accompany- 
ing illustration  (Fig.  138)  was  a 
workman,  forty  years  of  age.  who 
sustained  a  comminuted  fracture 
of  the  internal  malleolus  and  the 
sustentaculum  tali.  The  great 
toe  gradually  became  flexed  and 
contracted  tt)  such  a  degree  that 
at  the  present  time  the  nail  touches 
the  ground  when  the  i)atient  is 
standing.  The  muscles  of  the  foot 
are  greatly  atrophied.     Insurance  Pi„   133 

allowance,  33J%,  at  first;  at  pres- 
ent it  is  50  % . 

Ca^c  of  tmumnlic  Uilipcs  rarm  and  flat-foot  caused  by  fracture  of  the 
second  toe,  irhirh  lois  suhseqnentltj  removed,  together  with  a  jjortion  of  the 
Corresjio)idiin/  iik  laliirsiil  Ixiiie. 

The  patient  was  a  carpenter,  fifty  years  of  age,  who  was  injured  in 
Augtist,  1894,  l)y  a  piece  of  wood' falling  on  the  tip  of  his  left  foot. 
The  talipes  varus  is  marked;  the  third  and  fourth  toes  override  the 
first;  the  extensor  tendons  appear  very  tense,  especially  that  of  the 
tibialis  anticus,  and  the  muscles  of  the  leg  are  atrophied.  Insurance 
allowance,  33^%.  The  condition  of  the  jiatient  is  rather  worse,  if 
anything,  than  formerly. 


e526  DISEASES  CAUSED  BY  ACCIDENTS. 

Case  of  left  talipes  irinis^  folloiriiii/  a  fraeture  of  the  left  ley,  irith  dis- 
placement ancf  slioiieitiiu/.     (Fig.  V.id,  p.  5'27. ) 

A  mason,  t\vent,v-.se\-en  years  of  age,  feU  from  a  ladder  on  Deeember 
10,  1H!)2,  fraotui'ing  his  left  leg  in  its  lower  third.  Tiie  bones  healed 
with  lateral  disi)la(ement,  the  convexity  being  directed  outward,  the 
concavity  inward;  there  \va.s  an  extensive  growth  of  callus  and  the 
leg  was  distinctly  shortened.  The  patient  was  treated  in  the  hospital 
for  nine  weeks,  receiving  sul)sequently  an  insurance  allowance  of  4t)'/r , 
reduced  in  Deceml)er,  ls!)3,  to  20yr.  There  has  been  no  important 
change  in  his  condition  since  that  time.  The  sole-imjjressions  (P'ig. 
139)  show  the  difference  between  the  two  feet  very  well;  the  left 
imprint  is  smaller  than  the  right  and  the  foot  presents  a  curvature 
which  is  convex  externally,  conca\  e  internally. 

The  sole-impressions  of  tigure  140,  page  5:37,  show  a  slight  talipes 
varus  and  atrophy  of  the  foot,  with  Ci)nse(]uent  decrease  of  size  of  the 
tread,  following  a  fracture  of  the  right  thigii. 

Tlie  bones  were  much  displaced  at  the  point  of  fracture,  causing  a 
well-marked  genu  varum. 

The  jxitient  was  a  workman,  thirty-iive  years  of  age,  who  was 
crushed  by  a  wagon  against  an  iron  column.  He  was  treated  at  home 
by  splints  and  extension,  and  received  a  course  of  after-treatment  in 
my  hospital  from  October  24,  1898,  until  January  2^,  1899.  Insurance 
allowance,  30;;^. 

Dislocations  of  the  Toes. 

Unless  reduced,  tlie  usefulness  of  the  foot  may  bo  con- 
siderably affected  by  these  dislocations.  Dorsal  disloca- 
tion is  the  most  frequent  form,  and  is  most  often  seen  in 
the  case  of  the  great  toe.  Permanent  upward  displace- 
ment of  any  of  the  toes  is  always  a  serious  matter.  The 
])atient  is  forced  to  pay  great  attention  to  his  shoe,  to  see 
that  it  is  properly  shaped  and  well  made;  yet,  even  with 
this  precaution,  iujury  of  the  skin  over  the  ])rojectiug 
toes  can  not  well  be  avoided,  and  abrasions  frequently 
occur,  requiring  surgical  treatment.  The  toes  being  more 
or  less  stiff,  the  mid-tarsal  joint  and  ankle-joiut  become 
secondarily  aft'ected  ;  muscular  atrophy,  Ix'gimiiug  in  the 
foot,  proceeds  U})ward  along  the  leg  and  thigh  initil  even 
the  buttocks  become  wasted  on  the  affected  side.  Patients 
complain  of  the  foot  feeling  cold,  es])ecially  in  winter. 
These  sym])toms  are  in  many  cases  gradually  oxcrcome  to 
a  certain  extent,  but  they  never  completely  disapjiear. 
Permanent  dislocation  of  the  toes  downward  interferes 


528 


DISEASES   CAUSED  BY  ACCIDENTS. 


greatly  with  walking  and  standing.     This  form  of  dislo- 
cation is  most  often  seen  in  the  fourth  and  fifth  toes. 

The  accompanying  sole-impressions  (Fig.  141 )  illustrate  the  case 
of  a  workman,  tliirty-five  years  of  age,  who  sustained  a  compound 
comminuted  fracture  of  the  toes  and  metatarsal  bones  of  the  right  foot, 


Fig.  141. 


which  was  crushed  under  a  heavy  l>eam.  A  marked  case  of  club-foot 
was  the  result.  The  great  toe  is  displaced  upward  to  a  eonsideralile 
extent,  and  is  (luitc  stiff;  the  second  and  third  toes  had  to  be  removed; 
the  fourth  and  fifth  are  tightly  flexed  and  touch  the  gi'ouud  in  walk- 
ing,    Insurance  allowance,  100;^, 


FRACTURES  OF  THE  TOES.  529 

Disarticulation  leaves  the  foot  much  more  useful  than 
it  can  possibly  be  when  the  toes  are  permanently  dislo- 
cated, and  patients  should  be  strongly  advised  to  submit 
to  this  operation  or  to  amputation  of  the  toes. 

In  cases  of  permanent  partial  or  complete  dislocation 
of  the  toes  upward  the  working  capacity  is  diminished  by 
33^^  to  50^,  or  over,  and  an  equally  high  rate  may  be 
warranted  in  cases  of  dislocation  downward. 


Fractures  of  the  Toes. 

(117  Cases. ) 

These  fractures,  which  occur  when  the  foot  is  crushed, 
are  likely  to  be  compound  and  to  extend  to  adjacent  parts 
of  the  metatarsal  bones.  They  are  produced  by  the  im- 
pact of  heavy  objects,  such  as  stones,  slabs  of  granite, 
beams,  iron  rails,  etc.  The  severity  of  the  injury  depends 
both  on  the  surface  on  which  the  foot  rests  at  the  time  of 
accident  and  on  the  weight  of  the  object  by  which  it  is 
crushed.  We  frequently  have  to  deal  with  badly  commi- 
nuted fractures  requiring  the  amputation  of  a  portion  or 
of  the  whole  of  the  foot.  The  very  effort  of  the  surge(»n 
to  preserve  as  much  of  the  foot  as  possible  sometimes,  far 
from  giving  the  patient  a  relatively  serviceable  member, 
results  in  a  deformity  which  greatly  adds  to  his  functional 
disability.     (See  Plate  39,  Fig.  1.) 

The  great  toe  is  the  one  which  most  often  suffers  alone. 
The  fractures  of  the  metatarsophalangeal  joint,  having 
already  been  discussed  in  connection  with  the  metatarsal 
bones,  can  be  passed  over  here.  Nor  does  the  ankylosis 
which  follows  tliese  fractures  need  any  ex))hination.  After 
a  compound  fracture  at  this  joint  the  circulation  of  the 
great  toe  is  likely  to  be  imj)ed('(l  by  the  scar  encircling 
the  injured  joint.  Tlie  toe  therefore  apjiears  cyanotic  for 
a  long  time  after  recovery  (see  Plate  39,  Fig.  2) ;  the 
tem]>erature  of  the  part  is  lowered,  or,  occasionally,  is 
somewhat  raised.  The  toe  is  exceedingly  sensitive  to 
34 


530  DISEASES  CAUSED  BY  ACCIDENTS. 

cold,  a  matter  of  considerable  importance  to  workmen 
employed  out  of  doors  during  the  winter.  An  insurance 
allowance  is  justified  on  this  point  alone;  it  is  also  based, 
however,  on  the  stiffness  of  the  metatarsophalangeal  joint, 
which  in  many  cases  obliges  the  patient  to  walk  on  the 
outer  border  of  the  foot.  In  view  of  these  facts  it  would 
be  unreasonable  to  agree  to  the  position  taken  by  some 
that  a  stiff  great  toe  does  not  warrant  an  insurance 
allowance. 

Ankylosis  of  the  distal  phalangeal  joint  has  a  less 
unfavorable  effect,  but  even  this  is  to  a  large  extent  an 
individual  matter.  Compound  or  comminuted  fractures 
of  this  joint  often  require  a  comparatively  long  course  of 
treatment,  aud  jxiin  and  disturbances  of  gait  may  be 
marked  symptoms. 

Fractures  accompanied  by  crushing  of  the  distal  pha- 
lanx lead  almost  invariably  to  the  destruction  of  the 
nail-bed  ;  a  suppurative  onychia  frequently  follows  the 
injury,  the  nail  is  tlirown  off,  and  the  whole  distal  phalanx 
becomes  wasted  ancT deformed.  I  have  sometimes  observed 
a  subsequent  rudimentary  growth  of  the  nail,  but  have 
never  known  it  to  cover  the  whole  nail-bed.  It  is  likely 
to  grow  very  tliick  at  the  posterior  border  of  the  matrix, 
constantly  requiring  careful  trinnning  to  avoid  pressure 
from  the  shoe ;  but  although  processes  of  apparently 
healthy  nail  frequently  grow  out  forward,  they  always 
fall  off  again,  leaving  the  whole  front  part  of  the  nail- 
bed  covered  by  a  soft  corneous  layer,  which  completely 
merges  into  the  skin  in  front  and  at  the  sides.  In  one 
such  case,  which  I  have  had  under  observation  for  ten 
years,  the  condition  of  his  toe  still  causes  the  i)atient  con- 
siderable discomfort. 

The  effect  of  the  ankylosis  of  individual  toes  on  the 
usefulness  of  the  foot  depends,  among  other  things,  on 
the  position  of  the  affected  toe.  The  extent  to  which  the 
patient  may  be  disabled  has  already  been  discussed. 

The  stiffness  and  deformity  of  the  toes  after  severe 


iMg.  H2 


532  DISEASES   CAUSED  BY  ACCIDENTS. 

couimiuuted  fractures  may  so  lessen  the  usefulness  of  the 
foot  as  to  render  their  amputation  or  disarticulation  desir- 
able. Even  after  such  operations,  especially  if  parts  of 
the  corresponding  metatarsal  bone  have  to  be  sacrificed, 
there  may  remain  serious  interference  with  function. 

Case  of  frndure  of  the  disfal  phalan.r  of  the  (jrcal  foe.  (Fig.  142, 
p.  531.) 

A  workman,  forty-seven  years  of  age,  sustained  tlie  foregoing  lesion 
in  September,  1898,  when  a  heavy  stone  fell  on  and  crushed  his  great 
right  toe.  The  blood  extravasation  was  opened  by  tlie  surgeon  who 
dressed  the  foot.  Tlie  patient  lay  in  bed  for  two  weeks  and  began  to 
work  at  the  end  of  the  third  \veek.     He  made  a  perfect  recovery. 

Case  of  fracture  of  the  distal  jihulanx  of  the  great  toe  whieh  icas  crushed 
hy  an  iron  rail.      (Fig.  14:>,  p.  ^).\\\.) 

The  accompanying  skiagraph  (Fig.  143)  shows  the  line  of  fracture 
on  the  tip  of  the  great  toe  \ery  distinctly.  The  treatment  in  this  C£ise 
consisted  of  compresses  and  rest  in  lied;  the  patient  began  to  walk 
two  weeks  after  tlie  accident,  and  resumed  work  in  four  weeks.  The 
skiagraph  was  taken  at  the  latter  time. 

The  scar  resulting  from  the  amputation  of  the  great 
toe  and  a  portion  of-  the  first  metatarsal  bone  is  sensitive 
to  pressure,  and  interferes  with  walking  if  it  extends  out 
on  the  under  surface  of  the  ball  of  the  great  toe  ;  hence 
the  patient  steps  on  the  outer  part  of  the  sole.  He  has, 
in  addition,  lost  the  sujiport  of  the  head  of  the  metatarsal 
bone.  Disarticulation  of  the  toe  at  the  metatarsophalan- 
geal joint  has  an  equally  unfavorable  effect  if  the  scar  is 
so  placed  as  to  interfere  Avith  walking.  Even  when  the 
latter  is  not  ex])osed  to  ])ressure,  it  may  give  trouble  fir 
some  time  by  forming  adhesions  with  the  bone.  Many 
cases  of  disarticulation  at  this  joint,  however,  have  a  very 
favorable  functional  result. 

The  opposite  eifect,  as  to  position  of  the  foot,  is  seen 
after  removal  of  the  fifth  toe  or  of  the  fourth  and  fifth 
toes,  together  with  a  portion  of  their  metatarsal  bones,  the 
patient  using  the  inner  border  of  the  foot  in  walking,  both 
on  account  of  the  location  of  the  scar  and  because  the 
normal  outer  suj)])ort  of  the  foot  is  lacking.  These  dis- 
advantages are  not  found  after  disarticulation  of  the  fifth 


Fig.  14:3. 


534  DISEASES   CAUSED   BY  ACCIDENTS. 

toe  or  of  the  fourth  and  fifth  toes  at  the  metatarsophalan- 
geal joints. 

The  retraction  of  the  cicatrix  after  amputation  of  the 
second  toe  and  a  portion  of  the  second  metatarsal  bone 
may  go  so  far  as  to  cause  the  third  toe  to  override  the 
great  toe. 

The  insurance  allowance  for  loss  of  the  great  toe  is 
rated  at  from  10^  to  15^.  An  unfavorable  scar  and 
inability  to  walk  on  the  inner  border  of  the  foot  further 
increase  the  incajiacity,  and  raise  tlie  rate  accordingly. 
The  loss  of  each  of  the  other  toes  is  compensated  for  by 
5fc  ;  here,  too,  a  higher  rate  is  allowed  in  unfavorable 
cases. 

Amputation  of  all  the  toes  may,  if  the  scar  is  favorably 
located,  leave  a  comparatively  useful  member,  the  patient 
being  able  to  perform  heavy  work.  If  so,  an  insurance 
allowance  of  from  20  fo  to  25  ^  is  sufficient. 

The  usefulness  of  the  foot  is  much  more  impaired  l)y 
the  loss  of  all  the  metatarsal  bones  (Lisfranc's  opera- 
tion). For  workmen  who  are  obliged  to  be  on  their  feet, 
and  possibly  to  carry  heavy  loads,  from  33^^  to  40^ 
should  certainly  be  the  mininunn  rate.  In  a  few  cases  per- 
sonally known  to  me  the  ])atient  has  received  60^  for 
several  years. 

After  Chopart's  o])eration,  and  to  a  still  greater  degree 
after  Pirogotf 's  operation,  the  patient  is  quite  unfitted  for 
heavy  work  or  to  carry  weights.  For  these  cases  an  in- 
surance allowance  of  50^;  is  indicated. 

It  should  be  borne  in  mind  that  steadiness  in  walking 
and  standing  depends  on  the  size  of  the  surface  of  the  foot 
Avhich  comes  in  contact  with  the  ground.  When  this  is 
dinn'nislu'd  by  contracted  scars,  by  atrophy  of  the  nuiscles 
and  the  [)lantar  fat,  or  by  deformity  of  any  kind,  the  gait 
suffers  a  proportionate  loss  of  steadiness. 


INJURIES  OF  THE  FOOT  AND  INSURANCE.         535 


Traumatic  Tuberculosis  of  the  Foot. 

Tuberculous  foci  are  frequently  developed  in  the  bones 
of  the  tarsus  or  in  the  ankle-joint,  especially  as  a  result 
of  slight  injuries,  such  as  contusions  or  sprains.  Many 
such  instances  have  been  reported.  I  have  cited  a 
number  in  the  foregoing  pages,  accompanying  some  of 
them  with  illustrations. 


Rate  of   Indemnity  for  Deformities  of  the  Foot. 

A  rate  of  33J^  is  ample  for  an  absolutely  stiff  ankle, 
unless  talipes  valgus  or  varus  exists  at  the  same  timCj 
when  it  may  need  to  be  higher. 

Among  the  paralyses  of  the  foot  and  leg  with  which  we 
have  to  deal  the  paralysis  of  the  muscles  supplied  by  the 
peroneal  nerve  deserves  special  consideration.  This  is 
most  apt  to  occur  in  alcoholic  subjects,  but  is  not  con- 
fined to  them.     The  sym})tonis  are  often  quite  severe. 

In  one  case  coming  iinder  my  observation  the  muscles  in  question 
■were  completely  paralyzed,  and  the  patient  was  obliged  to  wear  a  shoe 
with  side  braces  in  order  to  walk  at  all.  He  received  40^  insurance 
allowance.  In  another  case  the  patient,  who  was  a  heavy  drinker, 
suffered  from  a  complete  sensory  paralysis  of  the  area  supplied  by  the 
peroneal  nerve  for  t\\  o  days  after  eveiy  spree.  Deep  pin-jiricks  cau.sed 
no  pain.     The  anesthesia  was  followed  by  extreme  hyperesthesia. 

Paralyses  of  liaV)it  are  sometimes  observed.  A  patient, 
for  instance,  walks  on  the  outer  border  of  the  foot  because 
of  some  painful  condition  of  the  inner  portion  of  the  sole; 
the  tibialis  anticus  becomes  contracted,  which  finally  leads 
to  spastic  paralysis  of  the  antagonists,  and  to  permanent 
deformity  of  the  foot. 

In  making  an  examination  of  the  lower  extremities  it 
is  essential  to  compare  the  two  sides — first  with  the 
patient  lying  on  the  back,  then  standing,  with  the  feet 
placed  ])arallel. "  The  examination-stool  which  I  have 
designed  will  be  found  very  serviceable.     The  gait  should 


536  DISEASES  CAUSED  BT  ACCIDENTS. 

be  tested,  and  the  condition  of  the  sole  of  the  foot  should 
be  ascertained  ;  finally,  it  is  necessary  to  determine  the 
strength  of  the  injured  foot  or  leg,  both  in  itself  and  in 
comparison  with  that  of  the  other  side. 


INDEX. 


Abdomen,  injuries  and  traumatic 

diseases  of,  "ilS 
Abdominal  hernia,  PI.  15 

muscles,  subcutaneous  rupture 
of,  213 

wall,  wounds  of,  212 
Abrasions,  44 
Abscess  of  brain,  105 
Accident-neiu-osis,  108 
Accidents,  causes  of,  33 

classification  of,  35 

due  to  poisoning,  81 

fatal  cases,  37 

statistics  of,  35 
Acliillodynia,  traumatic,  477 
Acromioclavicular      articulation, 

sprains  of,  241 
Acromion,  fractures  of,  253 
Alcoholic  intoxication,  81 
symptoms,  82 

neuritis,  61 
Alcoholism,     chronic,     81.      See 

also  Alcoholic  intoxication. 
Amputation  of  toes,  529,  532 
Anemia  of  skin,  45 
Aneur^'sm  of  thoracic  aorta,  211 

traumatic,  50 
Ankle,  function  of,  448 

injuries  and  traumatic  diseases 
of,  448 

scars  of,  476 
Ankle-joint,      "dislocation"    of, 
456,  457 

fractures  of,  468 

movements  at,  450 

scars  on,  PI.  37 

"sprain"  of,  451,  457,  476 
Ankylosis  of  elbow-joint,  position 

inj^  284 


Ankylosis  of   shoulder-joint   due 
to    fracture    of    cla\acle,    PI. 
17 
Anthrax,  84 

of  intestmal  tract,  85 
Aorta,     thoracic,    aneurysm    of, 

211 
Apoplexy  from  head-injuries,  102 
Arm,  wounds  of,  264 
bites,  265 

deep,  of  axilla,  265 
rupt\ires  of  triceps,  266 
subcutaneous  ruptures  of  bi- 
ceps, 265;  PI.  19 
Arteriosclerosis,  56 
ArthritLs  deformans,  76 
of  knee-joint,  412 
pauperum,  76 
traumatic,  76 
tubercular,  77 
prognosis,  79 
sjTuptoms,  78 
treatment,  79 
Arthropathy,  79 
Articular  rheiimatisin,  76 
Astragalus,  dislocations  of,  457 
fractures  of,  469 
body,  469 
head,  470 

involving  tubercle,  475 
neck,  470 
Atony,  muscular,  49 
Atrophy,  muscular,  49 
diagnosis,  50 
prognosis,  51 
treatment,  51 
"of  disuse,"  49 
of  muscles  of  hand,  PI.  27 
of  nails,  46 


53- 


538 


INDEX. 


Babinski's  reflex,  129 
Back,  burns  of,  183 

cicatrices  of,  183 

contusions  of,  182 

lacerations  of  muscles  of,  183 

subcutaneous  rupture  of  mus- 
cles of,  184 

wounds  of,  183 
Biceps  of  arm,  rupture  of,  2G5, 

PI.  19 
Bladder,   injuries  and  traumatic 

diseases  of,  224 
Blood-poisoning,  41 
Blood-vessels,  injuries  and   trau- 
matic diseases  of,  55 
Bones,  contusions  of,  67 

fractures  of,  62 

function  of,  61 

injuries  and  traumatic  diseases 
of,  61 

structure  of,  61 
Brachial  plexus,  paralysis  of,  due 

to  injury  of  shoulder,  245 
Brain,  abscess  of,  105 

centers  of,  PI.  1 

compression  of,  100 

concussion  of,  99 

contusion  of,  101 ;  PI.  1 

hemorrhage  of,  105 

traumatic  diseases  of,  103 

tumor  of,  105 
Bullet-wounds,  40 
"  Burden -deformities, "  122 
Burns  of  back,  183 

of  face,  116 

of  fingers,  321 

of  forearm,  292 

of  hand,  321 

of  leg,  416 

of  neck,  121 

ti'eatment  of,  44 
Bursa,  intertrochanteric,   inflam- 
mation of,  363 
Bursa;,    injuries    and    traumatic 
diseases  of,  53 

of  knee,  injuries  of,  397 

of  shoulder,  injuries  of,  240 
Bursitis,  53 
Buttocks,  contusions  of,  356 


Calf,  rupture  of  muscles  of,  486 
Capsules,   injuries  and  traumatic 

diseases  of,  55 
Caput  obstipum,  121,  156,  243 
Carcinoma  of  kidney,  223 
of  liver,  220 
of  peritoneum,  218 
of  stomach,  215 
of  testicle,  225 
Carcinomata  of  spine,  171 
Caries  of  spine,  170;  PI.  9 
Carpus,  dislocations  of  bones  of, 
310;  PL  36 
at  carpometacarpal  joints, 

312 
pisiform,  311 
fractures  of  bones  of,  313 
Cauda  equina,  lesions  of,  140 
Centers  of  brain,  88;  PI.  1 
Cerebral  hemorrhages,  92 
Chest,  cicatrices  of,  191 
concussion  of,  190 
injuries  and  traumatic  diseases 

of,  186 
wounds  of,  191 
Chronic  alcoholism,  81.     See  also 

A  Icokolic  i)i  toxication. 
Cicatrices  of  back,  183 

of  chest,  191 
Cicatrix  atrophica,  42 

hypertrophica,  42 
Clavicle,  dislocation  of,  249 
backward,  250 
complete,  251 
downward,  251 
forward,  249 
upward,  250 
fractures  of,  241 
external  third,  247 
followed     by    ankylosis     of 

shoulder-joint,  PI.  17 
inner  third,  248 
reunited,  242;  PI.  16 
treatment,  248 
Club-foot,  505,  525 
Commotio  cerebri,   99      See  also 
Co7icussion  of  brain. 
pectoris,  190 
Compression  myelitis,  173 
of  brain,  100 


INDEX. 


539 


Compression,  traumatic,  of  spinal 

cord,  132 
Concussion  of  lirain,  99 

of  chest,  190 

of  spinal  cord,  133 
Concussion -injuries  of  heart,  209 
Contortionists,  122 
Contracture  of   trapezius   due  to 
contusions,  PI.  7 

of  wrist,  PI.  23 
Contractures,  hysteric,  113 

of  fingere,  344 
Contusion  of  brain,  101 ;  PI.  1 
Contusion-pneumonia,  205 
Contusions  of  arm,  264 

of  back,  182 

of  bones,  67 

of  buttocks,  356 

of  elbow-joint,  282 

of  face,  115;  PI.  5 

of  forearm,  290 

of  hand,  319 

of  head,  91 

of  hiiHJoint,  363 

of  joints,  70 

of  kidney,  221 

of  knee-joint,  394 

of  leg,  35,  413 

of  liver,  219 

of  penis,  226 

of  shoulder,  238 

of  skin,  38 

of  spine,  141 

of  stomach,  213 

of  thigh,  366 

of  thora.x,  187;  PI.  12 
Conus  terminalis,  lesions  of,  140 
Coracoid    process,    fractures    of, 

256.    See  also  Scapula,  fractures 

of. 

"Crick  in  the  back,"  184 
Crushing  of  foot,  478 

of  forearm,  290 

of  hand,  291 

of  testicle,  224 

of  toes,  478 
Costal  cartilages,  fracture  of,  201 
Coxa  valga,  379 

vara,  379 
Coxitis,  traumatic,  366 


Cubitus  valgus,  276,  279,  283 

varus,  276,  279,  283 
Cuboid,  dislocations  of,  503 

fractures  of,  504 
Cuneiform  bones,  dislocations  of, 
502 
fracture  of,  498,  500 


"  Decollejiext    traumatique, " 

141 
"Deformities,  burden-,"  122 

of  foot,  rate  of  indemnity  for, 
535 
Dementia  paralytica,  106 
Diabetes  as  sequel  to  head-injury, 

101 
Diplegia    brachialis    traumatica, 

136 
Dislocation  of  ankle-joints,  456 

of  astragalus,  457 

of  carpus,  310 

of  clavicle,  249 

of  cuboid,  503 

of  cuneiform  bones,  502 

of  elbow-joint,  283 

of  fibula,  head,  422 

of  hip-joint,  364 

of  inferior  maxilla,  120 

of  joints,  72 

of  knee-joint,  400 

of  metacarpal  bones,  325 

of  metatarsiil  bones,  504 

of  patella,  403 

of  pelvic  l)ones,  362 

of  peronei  tendons,  477 

of  radio-ulnar  joint,  308 

of  radius,  head,  294 

of  ribs,  201 

of  sacrum,  362 

of  sca]>h()itl,  494 

of  semilunar  tibrocartilages,  402 

of  shoulder-joint,  257 

of  spine,  147.     See  also  Spine, 
dinlocdfionx  of. 

of  sulx-alcaneoid  Ijursji,  479 

of  toes,  526 

of  vertebrae,  147 

of  wrist-joint,  309 


540 


INDEX. 


Dislocation-fractures  of  scaphoid, 

494 
Dura  mater,  inflaniniation  of,  103. 

See  also  Paehymtninfiitis. 
Dyspepsia,  nervous,  clue  to  injury 

to  stomach,  216 


Edema,  malignant,  86 
Elbow-joint,  anatomic  considera- 
tions, 280 

contusions  of,  282 

dislocations  of,  283 

functions  of,  280 

injuries  and  traumatic  diseases 
of,  280 

sprains  of,  282 
Elephantiasis   cruris   traumatica, 

414 
Emphysema,  pulmonary,  206 
Epilepsy,  100,  114 
Epiphyses  of   leg,   separation  of, 

442 
Erb's  palsy,  245,  246 
Erysipelas,  46 

of  head,  93 
Extramedullary  hemorrhage,  134 
Extremities,   lower,   injuries  and 

traumatic  diseases  of,  353.    See 

also  Lower  extremities. 


Face,  burns  of,  116 

contusions  of,  115;  PI.  5 
fracture  of  bones  of,  116 
injuries  of,  115 

paralysis  of,  with  atrophy,  PI.  6 
wounds  of,  116 
Fasciae,  injuries  and  diseases  of, 

54 
Femoral  hernia,  234 
Femur,  fractures  of,  370 
condyles,  391 
head,  371 

in  region  of  trochanters,  377 
lower  third,  382 
neck,  371 
shaft,  384 
spontaneous,  385 
symptoms,  382 


Femur,  fractures  of,  upper  half, 
380 
upper  third,  378 
function  of,  370 
pseudo-arthrosis  of,  385 
Fibula,  dislocations  of,  head,  PI. 
35 
fractures  of,  head,  420;   PI.  33 
Finger,  little,  loss  of,  346;    PI.  29 
shortened  and  stiffened  as  re- 
sult of  gangrene,  PL  30 
Fingers,  burns  of,  321 
contractures  of,  344 
fractures  of,  340 
function  of,  317 
incised  wounds  of,  337 
injuries  and  traumatic  diseases 
of,  337 
indemnity  for,  351 
insurance  allowance  for  loss  of, 

mutilation  of,  PI.  28 

paralyses  of,  346 

sprains  of,  338 

stumps  of,  345 

trophoneuroses  of,  346 
Flat-foot,  505,  506,  520 
Floating  kidney,  222 
Foot,  crushing  of,  478 

deformities  of,   rate  of  indem- 
nity, 535 

injuries  and  traumatic  diseases 
of,  448 

scars  of,  477 

traumatic  tuberculosis  of,  535 

wounds  of,  477 
Forearm,  ))urns  of,  292 

contusions  of,  290 

crushings  of,  290 

fractures  of,  292.  See  also  Ulna 
and  Ii(i(Iii(». 

injuries  and  traumatic  diseases 
of,  288 

rupture  of  muscles  and  tendons 
of,  PI.  20 

wounds  of,  291 
Fracture,  compound,  of  sternum, 
PI.  10 

malleolar,  457,  476 

of  bones  of  face,  117 


I 


INDEX. 


541 


Fracture  of  costal  cartilages,  201 
of  inferior  maxilla,  119 
of  nasal  bones,  PL  5 
of  ribs,  ununited,  PI.  10 
of  superior  maxilla,  119 
Fractures,  fatal  results  of,  67 
healed,  symptoms  of,  64 
of  acromion,  "253 
of  ankle-joint,  468 
of    astragalus,    469.      See   also 

Aftrayaltis,  fractures  of. 
of  bones,  62 

in  special  occupations,  66 

of  cfirpus,  313 
of  cervical  vertebra;,  151 
of  clavicle,  241 
of  cuboid,  504 

of  cuneiform  bones,  498,  500 
of   dorsal   vertebrte,   158.     See 

also  Dorsal  vertebrse. 
of  femur,  370.    See  also  Femur, 

fractures  of. 
of  fingers,  340.     See  also  Fin- 
gers, fractures  of 
of  forearm,  292.     See  also  Ulna 

and  Badius. 
of    humerus,     267.      See    also 

Ilidiifrus,  fractures  of. 
of  joints,  74 
of  knee-joint,  411 
of  leg,  417.     See  also  Leg,  frac- 
tures of 
of  lumbar  vertebrae,  158.     See 

also  Lumbar  vertebne. 
of  malleoli,  458 
of  metacarpal  bones,  326 
of  metatarsiil  Itones,  506 
of  fts  calcis,  4H0 
of  patella,  403 
of  ]jelvis,  357.     See  also  PeMs, 

fractures  of. 
of  radius,  295.    See  also  Radius, 

fractures  of. 
of* ribs,  194;"  PI.    11.      See  also 

RU)S,  fractures  of. 
of  sacrum,  359 
of  scai)hoid,  496 
of  scapula,  252 
of  skull,  93;  PI.  2,  3,  4 
of  spine,  150,  162 


Fractures  of  sternum,  193 

of  tibia,  417 

of  toes,  529 

of  ulna,  294.      See  also    Ulna, 
fractures  of. 

of  vertebrae,  150 

spontaneous,  66 

supramalleolar,  438 
Frost-bites,  45 
Functional  neuroses,  107,  109 


CtAXGeexe,  45 

Gastric  hernia,  234 

Genu  valgum  after  leg  fracture, 

418;  PI.  34 
Glanders,  SQ 
Gloasy  skin,  41,  45 
Gout,  76 


Hallux  valgus,  510 

varus,  510 
Hand,  atrophy  of  muscles  of,  PI. 
27 

burns  of,  321 

contusions  of,  319 

crushing  of,  291 

injuries  and  traumatic  diseases 
of,  317 
indemnity  for,  351 

stiff,  Pi.  24 

trophoneurosis  of ,  58;  PI.  22 

wounds  of,  322 
Head,  contusions  of,  91 

ervsi]«'las  of,  \)'.\ 

injuries  and  traumatic  diseases 
of,  88 
Heart,  injuries  and  traumatic  dis- 
eases of,  208 
Heart-disease,  influence  of   trau- 
matism on  })rcexisting,  210 
Hematocele    of    testicle    due    to 

crushing,  224 
Hematomyelia,  traumatic,  135 
Hcmatorriiachis,  134 
Hemianesthesia,  112 
Hemoptysis    from  fractured    rib, 

206 


542 


INDEX. 


Hemorrhage,  extrameduUary,  134 

of  brain,  105 
Hemorrhages,  cerebral,  92 
intramedullary,  137 
traumatic,   in  spinal  cord,   135 
Hernia,  227 
abdominal,  PL  15 
femoral,  234 
gastric,  234 
inguinal,  228 

compensation  for,  231 
strangulated,    cicatrix   after, 

PI.  14 
treatment,  231 
umbilical,  234 
ventral,   234 

intensified    by    traumatism, 
PI.  13 
Hip-joint,  anatomy,  353 
contusions  of,  363 
dislocations  of,  364 
function  of,  353 
inflammation  of,  306 
injuries  and  traumatic  diseases 

of,  363 
movements  of,  355 
sprains  of,  363 
Humerus,  fractures  of,  267 
after-treatment,  280 
greater  tuberosity  of,  270 

symptoms,  270 
head  of,  267 

symi)toms,  268 
lesser  tuberosity  of,  271 

treatment,  272 
lower    articular     extremity, 
279 
end,  275 

cubitus  valgus,  276 

varus,  276 
svmptoms,  276 
half,  275 
middle  half,  275 
position  of  varus,  274 
separation  of   upper  epiphy- 
sis in,  272 
surgical  neck  of,  273 

united,  272 
upper  half  of,  274 
third  of,  274 


Hydrocele  due  to  crushing  of  tes- 
ticle, 224 

Hydronephrosis,  traumatic,  223 

Hyperesthesia,  113 

Hypertrophic  cervical  pachymen- 
ingitis, 172 

Hyijertrophy,  miiscular,  49 

Hypochondriasis,  111 

Hysteria,  111 

symptoms,  hemianesthesia,  112 
hyperesthesia,  113 
hysteric  contractures,  113 
paralysis,  113 
treatment,  113 

Hysteric  contractures,  113 


iNfiSED  wounds,  39 
India-rubber  men,  122 
Infected  wounds,  40 
Infectious    diseases,    traumatism 

and,  83 
Inflammation  of  dura  mater,  103. 
See  also  Pachymeningitis. 
of  kidney,  221 
of  pericardium,  208 
of  spinal  cord,  173 
traumatic,  of  pia  mater,  104 
Inguinal  hernia,  22^ 
Injuries  and   traumatic   diseases 
of  abdomen,  212 
of  ankle,  448 
of  arm,  264 
of  liladder,  224 
of  blood-vessels,  55 
of  bones,  61 
of  capsules,  55 
of  chest,  186 
of  elbow-joint,  280 
of  face,  115 
of  fascia;,  54 
of  fingers,  337 
of  foot,  448 
of  forearm,  288 
of  hand,  317 
of  head,  88 
of  heart,  208 
of  hip-joint,  363 
of  intestines,  216 
of  joints,  70 


INDEX. 


543 


Injuries   and   traumatic   diseases 
of  kidney,  2'21.    See  also 
Kidney. 
of  knee,  392 
of  leg,  413 
of  ligaments,  55 
of  liver,  219 

of  lower  extremities,  353. 
See  also  Lower  extremities 
of  lungs,  205 
of  muscles,  47 
of  nails,  46 
of  neck,  121 
of  nerves,  57 
of  pancreas,  220 
of  pelvis,  356 
of  penis,  226 
of  pericardium,  208 
of  peritoneum,  216 
of  skin,  38 
of  spleen,  220 
of  stomach,  213 
of  tendons,  52 
of  thigh,  366 
of  ureters,  225 
of  wrist-joint,  304 
of  spinal  cord,  132 
symptoms,  138 
meninges,  133 
of  spine,  141 
Intercostal  neuralgia,  202 
Intertrochanteric    bursa,    inflam- 
mation of,  363 
Intestinal  occlusion,  217 
stenosis,  217 
tract,  anthrax  of,  85 
Intestines,  injuries  and  traumatic 

diseases  of,  216 
Intoxication,  alcoholic,  ^\ 
Intramedullary  hemorrhages,  137 
Ischemic    paralysis    of     forearm 
after  fracture,'  296,  298 


Joints,  contusions  of,  70 
dislocations  of,  72 
fractures  of,  74 
injuries  and  traumatic  diseases 

of,  70 
resection  of,  79 


Kidney,  carcinoma  of,  223 

contusion  of,  221 

crushing  of,  221 

floating,  222 

inflammation  of,  221 

injuries  and  traumatic  diseases 
of,  221 

lacerations  of,  221 

penetrating  wounds  of,  223 
Klumpke's  palsy,  247 
Knee,  function  of,  392 

injuries  and  traumatic  diseases 
of,  392 
of  bursse,  397 

scare  of,  398 

wounds  of,  398 
Knee-jerk  in  injury  to  spinal  cord, 

128 
Knee-joint,  arthritis    deformans, 
412 

chronic  traumatic  inflammation 
of,  412 

contusions  of,  394 

dislocations  of,  400 

fractures  of,  411 

osteo-arthritis  of,  412 

sprains  of,  395 

subluxation  of,  401 

tuberculosis,  411 
Kummel's  disease,  144,  163 


Lacerated  wounds,  39 
Lacerations  of  kidney,  221 
of  mus<'les  of  hack,  183 
of  ))lantai-  fascia,  478 
of  tlioracic  duct,  218 
Leg,  burns  of,  416 

contusions  of,  413;  PI.  35 

of  calf,  413 
fractures  of,  417 
lower  half,  424 
third,  4:54.  438 

near  ankle-joint,  438 
middle  tliird,  424 
near  knee,   n>< 
pseudo-arthrosis    aftei-,    447; 
PL  :U) 
inflammation  of,  414 


544 


INDEX. 


Leg,  injuries  and  traumatic  dis- 
eases of,  413 
scalds  of,  416 

separation  of  epiphyses,  442 
wounds  of,  415 
Leptomeningitis,  104,  134 
Ligaments,  injuries  and  trauma- 
tic diseases  of,  55 
Ligamentum  patellse,  ruptures  of, 

396,  397 
Liver,  carcinoma  of,  220 
contusious  of,  219 
crushing  of,  219 
injuries  and  traumatic  diseases 

of,  219 
ruptures  of,  219 
Lockjaw,  85 
Locomotor  ataxia,  178 
symptoms,  179 
treatment,  179 
Lumbago,  traumatic,  184 
Lungs,     injuries    and    traumatic 
diseases  of,  205 
tuberculosis  of,  traumatic,  207 


Maligxaxt  edema,  85 
"  ]\Ialleolar  fracture,"  457 
Malleoli,    fractures    of,    typical, 
458 
inversion,  464 
uncomplicated,  468 
Maxilla,  inferior,  dislocation  of, 
120 
fracture  of,  119 
pseudo-arthroses  in,  120 
superior,  fracture  of,  119 
Meninges  of  brain,  traumatic  dis- 
eases of,  103 
spinal,  injuries  of,  1 33 
Meningitis,     tubercular     basilar, 

104 
"Meningocele     spuria     trauma- 
tica," 141 
Meningomyelitis,  acute,  134 

chronic  syphilitic,  173 
Metacarpal  bones,  dislocations  of, 
325 
fractures  of,  326 
head,  334 


Metacarpal    bones,   fractures    of, 
sj'mptoms,  328 
treatment,  336 
Metacarpophalangeal    joint,    scar 
over,  346;  PI.  29 
joints,  sprains  of,  324 
Metatarsjil  bones,  dislocations  of, 
504 
fractures  of,  506 
Mind-blindness,  89 
Motor-paralyses,  129 
Multiple  sclerosis,  176 
Muscle  strain,  47 
Muscles,   injuries  and    traumatic 

diseases  of,  47 
Muscular  atony,  49 
atrophy,  49 
difignosis,  50 
prognosis,  51 
treatment,  51 
hyiiertrophy,  49 
Myelitis,  compression,  173 
Myomata  of  spine,  172 


Nails,  atrophy  of,  46 

injuries  and  traumatic  diseases 
of,  46 
Neck,  burns  of,  121 

injiuies  and  traumatic  diseases 
of,  121 

wry-,  121 
Nephritis,  traumatic,  221 
Nerves,  dislocations  of,  58 

injuries  and  traumatic  diseases 
of,  57 
Nervous  dyspepsia  due  to  injury 

to  stomach,  216 
Neuralgia,  59 

intercostal,  202 
Neurasthenia,  110 

spinal,  181 
Neuritis,  57,  58,  60 

alcoholic,  61 
Neiu'oglia,    traumatic    inflamma- 
tion of,  174 
Neuroses,  functional,  107,  109 
Neurosis,  accident-,  108 

traumatic,  107 
Nose,  fracture  of  bones  of,  PI.  5 


i 


INDEX. 


545 


OccLUSiox,  mteptinal,  217 

O-position  in  fracture  of  humerus, 
276,  279,  283 

Orchitis,     suppurative,     due     to 
cnisliiiig  of  testicle,  224 

Os  calcis,  fractures  of,  480 
compression,  480 
internal  tubercle,  491 
"open  duck-bill,"  486 
sustentaculum  tali,  488 
symptoms,  481 
treatment,  484 
subluxation  of,  479 

Osteitis,  tubercular,  69 

Osteo-arthritis  of  knee-joint,  412 

Osteomyelitis,  traumatic,  68 


Pachymexixgitis,  103 

hypertrophic  cervical,  172 

spinal,  134 
Palsy,  Erb's,  245,  246 
Pancreas,  injuries  and  traumatic 

diseases  of,  220 
Paralysis,  57,  58 

agitans,  180 

Erb's,  245,  246 

Klumpke's,  247 

of  fingers,  346 

of  thigh,  38(;.     See  also  Tliigh, 
parnhjsiii  of. 

of  tilnar  nerve  due  to  crushing 
of  shoulder,  PI.  30 

progressive,  106 
Paraplegia,  spastic,  177 
Patella,  dislocations  of,  40:? 

fractures  of,  403 
Pectoral  muscles,  wounds  of,  192 
Pelvis,  anatomy  of,  353 

disloc-ation  of  ])ones,  362 

fractures  of,  357 

function  of,  353 

injuries  of,  356 
Penis,  contusions  of,  226 

injuries  and  traumatic  diseases 
of,  226 

wounds  of,  226 
Pericarditis,  traumatic,  208 
Pericardium,     inflannnation     of, 

208 

35 


Pericardium,   injuries   and    trau- 
matic diseases  of,  208 
Perinephritis,  223 
Peritoneum,  carcinoma  of,  218 
injuries  and  traumatic  diseases 
of,  216 
Peritonitis,  traumatic,  217 
Peronei  tendons,  dislocation   of, 

477 
Phalanges,  function  of,  317 
Phj'sical  injuries,  general  consid- 
erations of,  38 
Pia  mater,   traumatic  inflanmia- 

tions  of,  104 
Plantar  fascia,  laceration  of,  478 
Pleurisy,  traumatic,  203 
Pneumonia,  contusion-,  205 
from  fractured  ribs,  205 
traumatic,  187 
Poisoning,  accidents  due  to,  81 
Poliomyelitis,  chronic  progressive 

anterior,  177 
Popliteal  space,  scars  in,  PI.  37 
Progressive  paralysis,  106 
Pseudo-arthrosis  after  fracture  of 
forearm,  296 
in  inferior  maxilla,  120 
of  femur,  385 

of  leg,  after  fracture,  447:   PI. 
3() 
Pidmonary  emphysema,  206 
I'unctured  \\()unds,  39 


Radio-vlxak  joint,  dislocations 

of,  30H 
Radius,  dislocations  of  head,  294 
fractures  of,   examination   for, 
298 
head,  295 
involving  bones    of    carpus, 

300 
shaft,  295 

prognosis,  295 
"sprain-fractures,"  298 
tyi)ic;il,  298 

diskx-ations  with,  300 
treiitment,  302 
Railway   lirain,    110.      See    also 
Neurasthtnia. 


546 


INDEX. 


Eailway    sijine,    110.      8ee    also 

Neurasthenia. 
Reflexes,  cutaneous,  129 

tendon-,  130 
Resection  of  joints,  79 
Rheiiniatisni,  articular,  76 
Ribs,  dislocation  of,  201 
fractures  of,  194  ;  PI.  11 
healing,  196 

sequels  of,    intercostal   neu- 
ralgia, 202 
traumatic  pleurisy,  203 
tuberculosis     of     lungs, 
207 
symptoms,  197 
relation  of  vertebral  column  to, 

125 
ununited  fracture  of,  PI.  10 
Ru})ture   of   abdominal   muscles, 
213 
of    ligamentum   patellse,    396, 

397 
of  pectoral  muscles,  192 
of     semilunar     flbrocartilages, 
402 
Ruptures  of  calf  muscles,^  486 
of  liver,  219 
of    thigh,    subcutaneous,    367 ; 

PI.  31 
of  triceps  of  arm,  266 


Sacru:m,  dislocations  of,  362 
fractures  of,  symptoms,  360 
Sarcomata  of  spine,  171 
Scalds  of  leg,  416 
Scaphoid,  dislocations  of,  494 
dislocation-fractures  of,  494 
fratitures  of,  496 
Scapula,  fractures  of  acromion  of, 
253 
treatment,  254 
body  of,  253 
coracoid  process,  256 
neck  of,  254 
Scars  on  ankle,  476  ;  PL  37 
on  calf,  PI.  37 
on  foot,  477 

on  knee,   398.      See  also  Knee.^ 
scars. 


Seal's  on  popliteal  space,  PI.  37 
on  thigh,  368 
on  wrist,  315 
Scar-keloids,  43  ;  PI.  21 
Sclerosis,  multiple,  176 
Secondary  degeneration,  trauma- 
tic, 174 
Semilunar  flbrocartilages,  disloca- 
tion of,  402 
rupture  of,  402 
Shoulder,  contusions  of,  2.38 
functions  of,  236 
injuries  of,  statistics,  237 
loose-jointedness,  237 
loss  of  function  of,  237 
paralyses  of  brachial  jdexus  d^^e 

to  injury  of,  245 
sprains  of,  241 
Shoulder-joint,    dislocations    of, 
257;  PI.  18 
synovitis  of,  263 
Skin,  anemia  of,  45 
contusions  of,  38 
injuries  and  traumatic  diseases 

of,  38 
tuberculo.sis  of,  46 
Skull,  fractures  of,  93  ;  PL  2,  3, 
4 
symptoms,  97 
Spastic  ])araplegia,  177 
Spinal  cord,  concussion  of,  133 
inflammation  of,  173 
injuries  of,  132 
lesions  of  cervical  region,  138 
of  dorsal  region,  139 
of  lumbar  region,  140 
strains  of,  146 

traumatic     compression     of, 
132 
diseases  of,  128-132,  170 
hemorrhages  in,  135 
irritability,  181 
meninges,  injuries  of,  133 

traumatic  diseases  of,  172 
neurasthenia,  181 
pachymeningitis,  134 
Spine,  carcinomata  of,  171 
caries  of,  170;    PL  9 
compression-fracture  of,  163 
contusions  of,  141 


INDEX. 


547 


Spine,  dislocations  of,  147 

fractures  of,  150,  162 

injuries  of,  141 

niyoniata  of,  172 

railway,  110.     See  also  Neuras- 
thenia. 

sarcomata  of,  171 

sprains  of,  145 

ti'auniatic  diseases  of,  170 

tuberculosis  of,  170;  PI.  9 

tumors  of,  influence  of  trauma- 
tism on  development  of,  171 
Spleen,    injuries    and    traumatic 

diseases  of,  220 
Spondylitis  traumatica,  144 
Spontaneous  fractures,  06 
Sprain-fractures  of  radius,  298 
Sprains,  70 

definition,  70,  30.-^ 

of    acromiocla\  icular    articula- 
tion, 241 

of  ankle-joint,  451 

of  elbow-joint,  282 

of  fingers,  338 

of  hii>-joint,  363 

of  knee-joint,  395 

of  metacarpophalangeal  joints, 
324 

of  shoulder,  241 

of  spinal  cord,  146 

of  spine,  145 

of  wri.st-joint,  307 
Statistics  of  accidents,  35 
Stenosis,  intestinal,  217 
Sternum,  wjmpound  fracture  of, 
PI.  10 

fractures  of,  193 
Stiff  hand,  PI.  24 
Stomach,  carcinoma  of,  215 

contusions  of,  213 

crushing  of,  213 

injuries  and  traumatic  diseases 
of,  213 

traumatic  ulcer  of,  214 
Strains  of  muscles  of  back,  1^3 
Subcalcaneoid   ])ursa,  dislocation 

of,  479 
Sul)luxation,  73 

of  knee-joint,  401 

of  OS  Ciilcis,  479 


Supramalleolar  fractures,  438 
Sustentaculum  tali,  fractures  of, 

488 
Synovitis  of  shoulder-joint,  263 
Syringomyelia,  traumatic,  174 


Tabes  dorsalis,    178.      See  also 
Locomotor  ataxia. 
traumatic,  178 
Talipes  planus,  520 
valgus,  503 
varus,  494,  503,  525 
Tenalgia  crepitans  of  wrist,  317 
Tendon-sheaths,  injuries  and  trau- 
matic diseases  of,  52 
Tendons,  injuries  and  traumatic 

diseases  of,  52 
Tenosynovitis,  52 

chronic,  at  wrist,  317 
Testicle,  carcinoma  of,  225 
crushing  of,  224 
cutaneous  wounds  of,  225 
injuries  and  traumatic  diseases 

of,  224 
loss  of  one,  225 
tuberculosis  of,  225 
Tetanus,  85 
Thigh,  contusions  of,  366 

injuries  and  traumatic  diseases 

of,  366 
paralysis  of,  386 
crural,  3^6 

symptoms,  390 
tmnk  f)f  sciatic  nerve,  390 
rupture  of,  suteutaueous,  367; 

PI.  31 
scars  of,  368 
wounds  of,  368 
Thoracic  duct,  laceration  of,  218 
Thorax,  contusion  of,  PI.  12 

contusions  of,  187 
Tibia,  fractures  of,  417 
ati-ophy  after,  PI.  35 
compression-,  PI.  33 

lower  end,  445 
shaft,  434 
upper  end,  417 
sym]>tonis,  417 
treatment,  418 


548 


INDEX. 


Toes,  amputation  of,  529,  5;}2 

crushing  of,  478 

dislocations  of,  526 

fractures  of,  529;  PL  39 
injury  to  nail-bed,  530 
Torticollis  due  to  fracture  of  clav- 
icle, PI.  17 
Trapezius,  contracture  of,  due  to 

contusions,  PI.  7 
Traumatic  arthritis,  76 

diseases  of  spinal  cord,  128-131 

disorders,     general     considera- 
tions of,  37 

flat-foot,  520 

lumbago,  184 

osteomyelitis,  68 

pericarditis,  208 

peritonitis,  217 

pneumonia,  187 

tabes,  178 
Traumatism,    general    considera- 
tions of,  37 

influence   on   development    of 
tumors,  80 
preexisting  heart-disea»se,  210 
Trophoneuroses  of  fingers,  346 
Trophoneurosis,  58 

of  hand,  58;  PI.  22 
Tul)ercular  arthritis,  77.  See  also 
Arfhrifis. 

basilar  meningitis,  104 

osteitis,  69 
Tuberculosis,  87 

of  foot,  traumatic,  535 

of  knee-joint,  411 

of  lungs,  traumatic,  207 

of  skin,  46 

of  spine,  170;  PI.  9 

of  testicle,  225 
Tuberculous  synovitisof  .shoulder- 
joint,  2()3 
Tumor  of  brain,  105 
Tumors,  influence  of  traumatism 
on  development  of,  80 

of  spine,  influence   of   trauma- 
tism on  development  of,  171 


Ulcer,    traumatic,  of    stomach, 
214 


Ulna,  fractures  of,  shaft,  294 

upper  third  with  dislocation 
of  head  of  radius,  294 
Ulnar  nerve,  paralysis  of,  due  to 

cru.shing  of  shoulder,  PI.  30 
Umbilical  hernia,  234 
Ureters,    injuries  and   traumatic 
diseases  of,  225 


Vakicose  veins,  56 
Ventral  hernia,  234 
Vertebrse,  dislocations  of,  147 
fractures  of,  150 
cervical,  151 
dorsal,  158 
lumbar,  158 
Vertebral     column,      anatomico- 
phvsiologic    considerations 
of,"  121-125 
mobility  of,  122 
relation  to  ribs,  125 


Wool-sorters'  disease,  84,  85 
Wounds,  39 

bullet-,  40 

caused  by  crushing,  39 

incised,  39 

infect«l,  40 

lacerated,  39 

of  atxlominal  wall,  212 

of  arm,   264.       See  also  Arm, 
troiuKh  of. 

of  back,  183 

of  chest,  191 

of  face,  116 

of  foot,  477 

of  forearm,  291.    See  also  Fore- 
arm, iroiuuJs  of. 

of  hand,  322 

of  intestine,  217 

of  kidnej',  penetrating,  223 

of  knee,  398 

of  leg,  415 

of  penis,  226 

of  testicle;  225 

of  thigh,  368 

punctured,  39 

treatment  of,  42 


INDEX. 


549 


Wrist,   chronic   tenosynovitis  of, 
317 

contracture  of,  PL  23 

scars  on,  315 

tenalgia  crepitans,  317 
Wrist-joint,  dislocations  of,  309 

f nnctions  of,  304 

injuries  and  traumatic  diseases, 
of,  304 

mobility  of,  307 


Wrist-joint,  movements  of,  306 

sprains  of,  307 
Wry-neck,  121 

due  to  fracture  of  clavicle,  PI. 
17 


X-POSITION  in  fracture  of  hum- 
erus, -276,  279,  283 


Medical  and  Surgical  Works 


PUBLISHED   BY 


W.  B.  SAUNDERS,  925  Walnut  Street,  Philadelphia,  Pa. 


PAGE 

Abbott  on  Transmissible  Diseases    .    .    .    .  i8 
American  Pocket  Medical  Dictionary    .    .  35 
*American  Text-Book  of   Applied   Thera- 
peutics     8 

*American  Text-Book  of  Dis.  of  Children  .  13 
*An  American  Text-Book  of  Diseases  of  the 

Eye,  Ear,  Nose,  and  Throat 15 

*An   American  Text-Book  of  Genito-Uri- 

nary  and  Skin  Diseases 14 

♦American  Text-Book  of  Gynecology  ...  12 
♦American  Text-Book  of  Legal  Medicine  .  44 
♦.■\merican  Text-Book  of  Obstetrics  ...  9 
♦American  Text-Book  of  Pathology  .  .  .  44 
♦American  Text-Book  of  Physiology  ...  7 
♦American  Text-Book  of  Practice  ....  10 
♦American  Text-Book  of  Surgery  .  .  11 
Anders'  Theory  and  Practice  of  Medicine  .  21 

Ashton's  Obstetrics 43 

Atlas  of  Skin  Diseases 28 

Ball's  Bacteriology 43 

Bastin's  Laboratory  Exercises  in  Botany  .  36 

Beck's  Surgical  Asepsis 41 

Boisliniere's  Obstetric  Accidents 39 

Brockway's  Physics 43 

Burr's  Nervous  Diseases 41 

Butler's  Materia  Medica  and  Therapeutics  24 
Cerna's  Notes  on  the  Newer  Remedies  .  .  32 
Chapin's  Compendium  of  Insanity  ....  35 
Chapman's  Medical  Jurisprudence  .  .  .  .  41 
Church  and  Peterson's  Nervous  and  Men- 
tal Diseases 17 

Clarkson's  Histology 33 

Cohen  and  Eshner's  Diagnosis 43 

Corwin's  Diagnosis  of  the  Thorax   ....  37 

Cragin's  Gynaecology 43 

Crookshank's  Text-Book  of  Bacteriology  .  27 

DaCosta's  Manual  of  Surgery 23 

De  Schweinitz's  Diseases  of  the  Eye  ...  29 
Dorland's  Pocket  Medical  Dictionary    .    .  35 

Dorland's  Obstetrics      41 

Frothingham's  Bacteriological  Guide  .    .    .30 

Garrigues'  Diseases  of  Women 34 

Gleason's  Diseases  of  the  Ear 43 

♦Gould  and  Pyle's  Curiosities  of  Medicine  .  17 

Grafstrom's  Massage 28 

Griffith's  Care  of  the  Baby 38 

Griffith's  Infant's  Weight  Chart 39 

Gross's  Autobiography 26 

Hampton's  Nursing 39 

Hare's  Physiology 43 

Hart's  Diet  in  Sickness  and  In  Health    .    .  36 

Haynes'  Manual  of  Anatomy 41 

Heisler's  Embryology 19 

Hirst's  Obstetrics 20 

Hyde's  Syphilis  and  Venereal  Diseases  .  .  41 
International  Text-Book  of  Surgery    ...    6 

Jackson's  Diseases  of  the  Eye 19 

Jackson  and  Gleason's  Diseases  of  the  Eye, 

Nose,  and  Throat 43 

Keating's  Pronouncing  Dictionary  ....  26 

Keating's  Life  Insurance 39 

Keen's  Operation  Blanks 36 

Keen's  Surgery  of  Typhoid  Fever  ....  22 


Kyle's  Diseases  of  Nose  and  Throat  ...  18 

Laine's  Temperature  Charts 32 

Levy  &  Klemperer's  Clinical  Bacteriology 44 
Lockwood's  Practice  of  Medicine    ....  41 

Long's  Syllabus  of  Gynecology 34 

Macdonald's  Surgical  Diagnosis  and  Treat- 
ment     22 

McFarland's  Pathogenic  Bacteria    ....  30 
Mallory  and  Wright's  Pathological  Tech- 
nique   22 

Martin's  Surgery 43 

Martin's  Minor  Surgery,  Bandaging,  and 

Venereal  Diseases 43 

Meigs'  Feeding  in  Early  Infancy 30 

Moore's  Orthopedic  Surgery 23 

Morris'  Materia  Medica  and  Therapeutics  43 
Morris'  Practice  of  Medicine     ......  43 

Morten's  Nurses'  Dictionary 38 

Nancrede's  Anatomy  and  Dissection  ...  31 

Nancrede's  Anatomy 43 

Nancrede's  Principles  of  Surgery  ....  19 
Norris'  Syllabus  of  Obstetrical  Lectures    .  37 

Penrose's  Diseases  of  Women 24 

Powell's  Diseases  of  Children 43 

Pryor's  Pelvic  Inflammations 33 

Pye's  Bandaging  and  Surgical  Dressing    .  23 

Raymond's  Physiology 41 

Saundby's  Renal  and  Urinary  Diseases  .    .  25 
♦Saunders'  American  Year-Book  of  Medi- 
cine and  Surgery 16 

Saunders'  Medical  Hand-Atlases  .  .  .  3,  4,  5 
Saunders'  Pocket  Medical  Formulary  .  .  35 
Saunders'  New  Series  of  Manuals  .  .  .  40,  41 
Saunders'  Series  of  Question  Compends  42,  43 

Sayre's  Practice  of  Pharmacy 43 

Semple's  Pathology  and  Morbid  Anatomy  43 
Semplc's  Legal  Medicine  and  Toxicology.  43 
Senn's  (jenito-Urinary  Tuberculosis  ...  24 

Senn's  Tumors 25 

Senn's  Syllabus  of  Lectures  on  Surgery  .  .  37 
Shaw's  Nervous  Diseases  and  Insanity  .    .  43 

Starr's  Diet-Lists  for  Children 38 

Stelwagon's  Diseases  of  the  Skin 43 

Stengel's  Pathology 20 

Stevens'  Materia  Sledica  and  Therapeutics  32 

Stevens'  Practice  of  Medicine 31 

Stewart's  Manual  of  Physiology 37 

Stewart    and    Lawrance's    Medical    Elec- 
tricity  43 

Stoney's  Materia  Medica  for  Nurses  ...  31 
Stoney's  Practical  Points  in  Nursing  ...  27 
Sutton  and  Giles'  Diseases  of  Women  .  29,41 
Thomas's  Diet-List  and  Sick-Rooni  ...  38 
Thornton's  Dose-Book  and  Manual  of  Pre- 
scription-Writing   ....        41 

Van  Valzah  and  Nisbet's  Diseases  of  the 

Stomach 21 

Vecki's  Sexual  Impotence 33 

Vierordt  and  Stuart's  Medical  Diagnosis  .  28 

Warren's  Surgical  I'athology 25 

Watson's  Handbook  for  Nurses 26 

Wolff's  Chemistry 43 

WolfTs  Examination  of  Urine 43 


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Swedish,  Roumanian,  Bohemian,  and  Hungarian. 

In  view  of  the  unprecedented  success  of  these  works,  Mr.  Saunders  has  con- 
tracted with  the  publisher  of  the  original  German  edition  for  one  hundred 
thousand  copies  of  the  atlases.  In  consideration  of  this  enormous  under- 
taking, the  publisher  has  been  enabled  to  prepare  and  furnish  special  additional 
colored  plates,  making  the  series  even  handsomer  and  more  complete  than 
was  originally  intended. 

As  an  indication  of  the  great  practical  value  of  the  atlases  and  of  the  im- 
mense favor  with  which  they  have  been  received,  it  should  be  noted  that  the 
Medical  Department  of  the  U.  S.  Army  has  adopted  the  "Atlas  of  Opera- 
tive Surgery,"  as  its  standard,  and  has  ordered  the  book  in  large  quantities  for 
distribution  to  the  various  regiments  and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been  secured  in 
the  English  edition  as  in  the  originals.  The  translations  have  been  edited  by 
the  leading  American  specialists  in  the  different  subjects. 

{For  List  of  Volumes  in  this  Series,  see  next  two  pages. ) 
3 


SAUNDERS^  MEDICAL  HAND-ATLASES« 

VOLUMES  NOW  READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  68  colored 
plates,  64  text-illustrations,  and  259  pages  of  text.     Cloth,  #3.00  net. 

"The  charm  of  the  book  is  its  clearness,  conciseness,  and  the  accuracy  and  beauty  of  its 
illustrations.  It  deals  with  facts.  It  vividly  illustrates  those  facts.  It  is  a  scientific  wforlc 
put  together  for  ready  reference." — Brooklyn  Medical  Journal. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited 
by  Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Dept.,  College 
of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates,  and  193  beautiful  half-tone  illustrations.      Cloth,  ^3.50  net. 

"  Hofmann's  'Atlas  of  Legal  Medicine'  is  a  unique  work.  This  immense  field  finds  in  this 
book  a  pictorial  presentation  that  far  excels  anything  with  which  we  are  familiar  in  any  other 
work." — Pliiladelfihia  Medical  Journal . 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.  By  Dr.  L.  Grunwald, 
of  Munich.  Edited  by  Charles  P.  Grayson,  M.  D.,  Physician-in-Charge, 
Throat  and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania. 
With  107  colored  figures  on  44  plates,  25  text-illustrations,  and  103  pages 
of  text.  Cloth,  ^2.50  net. 
"Aided  as  it  is  by  jnagnificently  executed    illustrations  in  color,  it  cannot  fail  of  being  of 

the  greatest  advantage  to  students,  general    practitioners,  and  expert  laryngologists." — St. 

Louis  Medical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl, 
of  Vienna.  Edited  by  J.  Chalmers  DaCosta,  M.  D.,  Professor  of  Prac- 
tice of  Surgery  and  Clinical  Surgery,  Jefferson  Medical  College,  Philadel- 
phia. With  24  colored  plates,  217  text-illustrations,  and  395  pages  of  text. 
Cloth,  ;S3.oo  net. 

"  We  know  of  no  other  work  that  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of  oper- 
ative surgery." — Miinchener  medicinische  Wochenschrift. 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Diseases.    By 

Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolion  Bangs, 
M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and  Bellevue  Hos- 
pital Medical  College,  New  York.  With  71  colored  plates,  16  black-and- 
white  illustrations,  and  122  pages  of  text.  Cloth,  ^3.50  net. 
"A  glance  through  the  book  is  almost  like  actual  attendance  upon  a  famous  clinic." — 
Journal  of  the  American  Medical  .4ssociation. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye.    By  Dr.  O- 

Haab,  of  Zurich.      Edited  by  G.  E.  nE  ScHWEiNiTZ,  M.  D.,  Professor  of 
Ophthalmology,  Jefferson  Medical  College,  Philadelphia.    With  76  colored 
illustrations  on  40  plates,  and  228  pages  of  text.     Cloth,  I3.00  net. 
"It  is  always  difficult  to  represent  pathological   appearances  in  colored  plates,  but  this 

work  seems  to  have  overcome  these  difficulties,  and  the  plates,  with  one  or  two  exceptions, 

are  absolutely  satisfactory." — Boston  Medical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Skin  Diseases.     By  Prof,  Dr.  Franz  Mracek, 
of  Vienna.     Edited  by  Henry  W.  Stelwagon,  M.  D.,  Clinical  Professor 
of  Dermatology,  Jefferson  Medical  College,  Philadelphia.    With  63  colored 
plates,  39  half- tone  illustration.s  and  200  pages  of  text.    Cloth,  53-5°  "^t- 
"The   importance  of  per.sonal  inspection   of  cases   in  the  study  of  cutaneous   diseases  is 
readily  appreciated,  and  next  to  the  living  subjects  are  pictures  which  will  show  the  appear- 
ance of  the  disease  under  consideration.     Altogether  the  work  will  be  found  of  very  great 
value  to  the  general  practitioner."— ybarwa/^  the  American  Medical  Association. 

4 


SAUNDERS^  MEDICAL  HAND-ATLASES. 


VOLUMES  IN  PRESS  FOR  EARLY  PUBLICATION. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.     By  Dr.  Ed. 

GOLEBIEWSK.1,  of  Berlin.  'I'ran4ated  and  edited  with  additions  by  Pearce 
Bailey,  M.D.,  Attending  Physician  to  the  Department  of  Corrections 
and  to  the  Almshouse  and  Incurable  Hospitals,  New  York.  With  40 
colored  plates,  143  text-illustrations,  and  600  pages  of  text. 
Atlas  and  Epitome  of  Special  Pathological  Histology.  By  Dr.  H. 
DOrck,  of  Munich.  Edited  by  LuDViG  Hektoen,  M.D.,  Professor  of 
Pathology,  Rush  Medical  College,  Chicago.  Two  volumes,  with  about 
120  colored  plates,  numerous  text-illustrations,  and  copious  text. 

Atlas  and  Epitome  of  General  Pathological   Histology.    With  an 

Appendix  on  Patho-histological  Technic.      By  Dr.  H.  DOrck,  of  Munich. 
Edited  by  LuDViG  Hektoen,  M.D.,  Professor  of  Pathology,  Rush  Medi- 
cal College,  Chicago.    With  80  colored  plates,  numerous  text-illustrations, 
and  copious  text. 
Atlas  and   Epitome  of  Gynecology.      By  Dr.  O.  Schaffer,  of  the 

University  of  Heidelberg.  With  90  colored  plates,  65  text- illustrations, 
and  308  pages  of  text.  Edited  by  Richard  C.  Norris,  A.  M.,  M.  D., 
Gynecologist  to  the  Philadelphia  and  the  Methodist  Episcopal  Hospitals. 

IN  PREPARATION. 

Atlas  and  Epitome  of  Orthopedic  Surgery.  By  Dr.  Schui.tess  and 
Dr.  I-unint,,  of  Zurich.      About  loo  colored  illustrations. 

Atlas  and  Epitome  of  Operative  Gynecology.  By  Dr.  O.  Schaffer, 
of  Heidelberg.  With  40  colored  plates  and  numerous  illustrations  in 
black  and  white  from  original  'paintings. 

Atlas  and  Epitome  of  Diseases  of  the  Ear.     Edited  by  Pr(m\  Dr. 

Politzer,  of  Vienna,  and  Dr.  G.  Briiil,  of  Berlin.  With  120  colored 
illustrations  and  about  200  pages  of  text. 

Atlas  and  Epitome  of  General  Surgery.  Edited  by  Dr.  Marwedel, 
with  the  cooperation  of  Prof.  Dr.  Czerny.  With  about  200  colored 
illustrations. 

Atlas  and  Epitome  of  Psychiatry.    By  Dr.  Wit.ii.  Wevcandt,  of  Wurz 

burg.      With  about  120  colored  illustrations. 

Atlas  and  Epitome  of  Normal  Histology.    I'.y  Dr.  Johannes  Sohotta. 

of  Wiirzburg.      With  80  colored  plates  and   numerous  illustrations. 

Atlas  and  Epitome  of  Topographical  Anatomy.  By  Prof.  Dr. 
SCHULTZE,  of  Wiirzburg.  About  lOO  colored  illustrations  and  a  very 
copious  text. 

5 


IV.   B.   SAUNDERS' 


*THE    INTERNATIONAL    TEXT-BOOK    OF    SURGERY.     In 

two  volumes.  By  American  and  British  authors.  Edited  by  J.  Col- 
lins Warren,  M.D.,LL.D.,  Professor  of  Surgery,  Harvard  Medical  School, 
Boston ;  Surgeon  to  the  Massachusetts  General  Hospital ;  and  A.  Pearce 
Gould,  M.  S.,  F.  R.  C.  S.,  Eng.,  Lecturer  on  Practical  Surgery  and  Teacher 
of  Operative  Surgery,  Middlesex  Hospital  Medical  School;  Surgeon  to  the 
Middlesex  Hospital,  London,  England.  Vol.  I. — General  and  Operative 
Surgery. — Handsome  octavo  volume  of  947  pages,  with  458  lieautiful 
illustrations,  and  9  lithographic  plates.  Vol.  H. — Special  or  Regional 
Surgery. — Handsome  octavo  volume  of  1050  pages,  with  over  500  wood- 
cuts and  half-tones,  and  8  lithographic  plates.  Prices  per  volume  :  Cloth, 
$5.00  net;  Half-Morocco,  ^6.00  net. 

Just  Issued. 

In  presenting  a  new  work  on  surgery  to  the  medical  profession  the  publisher 
feels  that  he  need  offer  no  apology  for  making  an  addition  to  the  list  of  excellent 
works  already  in  existence.  Modern  surgery  is  still  in  the  transition  stage  of  its 
development.  The  art  and  science  of  surgery  are  advancing  rapidly,  and  the 
number  of  workers  is  now  so  great  and  so  widely  spread  through  the  whole  o* 
the  civilized  world  that  there  is  certainly  room  for  another  work  of  reference 
which  shall  be  untrammelled  by  many  of  the  traditions  of  the  past,  and  shall  at 
the  same  time  present  with  due  discrimination  the  results  of  modern  progress. 
There  is  a  real  need  among  practitioners  and  advanced  students  for  a  work  on 
surgery  encyclopedic  in  scope,  yet  so  condensed  in  style  and  arrangement  that 
the  matter  usually  diffused  through  four  or  five  volumes  shall  be  given  in  one- 
half  the  space  and  at  a  correspondingly  moderate  cost. 

The  ever-widening-field  of  surgery  has  been  developed  largely  by  special 
work,  and  this  method  of  progress  has  made  it  practically  impossible  for  one 
man  to  write  authoritatively  on  the  vast  range  of  subjects  embraced  in  a  modern 
text-book  of  surgery.  In  order,  therefore,  to  accomplish  their  object,  the  editors 
have  sought  the  aid  of  men  of  wide  experience  and  established  reputation  in  the 
various  departments  of  surgery. 

C  OSTTRIBIITORS : 


Dr 


Robert  W.  Abbe. 
C.  H.  Golding  Bird. 
E.  H.  Bradford. 
W.  T.  Bull. 
T.  G.  A.  Burns. 
Herbert  L.  Hurrell. 
R.  C.  Cibot. 
I.  H.  Cameron. 
James  Cantlie. 
W.  Watson  Cheyne. 
William  B.  Cl.irke. 
William  B.  Coley. 
Edw.  Treacher  Collins. 
H.  Holbrook  Curtis. 
J.  Chalmers  Da  Costa. 
N.  P.  D.Tndridge. 
John  B.  De.iver. 
J.  W.  Elliot. 
Harold  Ernst. 


Dr.  Christian  Fenger. 
W.  H.  Forwood. 
George  R.  Fowler. 
George  W.  Gay. 
A.  Pearce  Gould. 
J.  Orne  Green. 
John  B.  Hamilton. 
M.  L.  Harris. 
Fernand  Henrotin. 
G.  H.  Makins. 
Rudolph  Matas. 
Charles  Mcliurncy. 
A.  J.  McCosh. 
L.  S.  McMurtry. 
J.  Ewing  Mears. 
George  H.  Monks. 
John  Murray. 
Robert  W.  Parker. 


.  Rushton  Parker. 
George  A.  Peters. 
Franz  Pfaff. 
Lewis  S.  Pilcher. 
James  J.  Putnam. 
M.  H.  Richardson. 
A.  W.  Mayo  Robson. 
W.  L.  Rodman. 
C.  A.  Siegfried. 
G.  B.  Smith. 
W.  G.  Spencer. 
J.  Bland  Sutton. 
L.  McLane  Tiffany. 
H.  Tuholske. 
Weller  Van  Hook. 
James   P.  VVarbasse. 
J.  Collins  Warren. 
De  Forest  Willard. 


CATALOGUE    OF  MEDICAL    WORKS.  7 

*AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
William  H.  Howell,  Ph.  D.,  M.  D.,  Professor  of  Physiology  in  the 
Johns  Hopkins  University,  Baltimore,  Md.  One  handsome  octavo  volume 
of  1052  pages,  fully  illustrated.  Prices  :  Cloth,  ;JS6.CX)  net;  Sheep  or  Half- 
Morocco,  $7.00  net. 

This  work  is  the  most  notable  attempt  yet  made  in  America  to  combine  ii? 
one  volume  the  entire  subject  of  Human  Physiology  by  well-known  teachers 
who  have  given  especial  study  to  that  part  of  the  subject  upon  which  they  write. 
The  completed  work  represents  the  present  status  of  the  science  of  Physiology, 
particularly  from  the  standpoint  of  the  student  of  medicine  and  of  the  medical 
practitioner. 

The  collaboration  of  several  teachers  in  the  preparation  of  an  elementary  text- 
book of  physiology  is  unusual,  the  almost  invariable  rule  heretofore  having  been 
for  a  single  author  to  write  the  entire  book.  One  of  the  advantages  to  be  derived 
from  this  collaboration  method  is  that  the  more  limited  literature  necessary  for 
consultation  by  each  author  has  enabled  him  to  base  his  elementary  account 
upon  a  comprehensive  knowledge  of  the  subject  assigned  to  him;  another,  and 
perhaps  the  most  important,  advantage  is  that  the  student  gains  the  point  of  view 
of  a  number  of  teachers.  In  a  measure  he  reaps  the  same  benefit  as  would  be 
obtained  by  following  courses  of  instruction  under  different  teachers.  The 
different  .standpoints  assumed,  and  the  differences  in  emphasis  laid  upon  the 
various  lines  of  procedure,  chemical,  physical,  and  anatomical,  should  give  the 
student  a  better  insight  into  the  methods  of  the  science  as  it  exists  to-day.  The 
work  will  also  be  found  useful  to  many  medical  practitioners  who  may  wish  to 
keep  in  touch  with  the  development  of  modern  physiology. 

rONTRIBlTTORS : 


HENRY  P.  BOWDITCH,  M.  D., 

Professor  of  Physiology,  Harvard  Medi- 
cal School. 

JOHN  G.  CURTIS,  M.  D., 

Professor  of  Physiology,  Columbiii  Uni- 
versity, N.  Y.  (College  of  Physicians 
and  Surgeons). 

HENRY  H.  DONALDSON,  Ph.D., 

Head-Professor  of  Neurology,  Univer- 
sity of  Chicago. 

W.  H.  HOWELL,  Ph.  D.,M.D., 

Professor  of  Physiology,  Johns  Hopkins 
University. 

FREDERIC  S.  LEE,  Ph.  D., 

Adjunct  Professor  of  Physiology,  Cohim- 


WARREN  P.  LOMBARD,  M.D., 

Professor   of   Physiology,  University  of 
Michigan. 

GRAHAM  LUSK,  Ph.D., 

Professor   of  Physiology,   Yale   Medica/ 
School. 

W.  T.  PORTER.  M.  D., 

Assistant  Professor  of  Physiology,  Har- 
vard Medical  School. 

EDWARD  T.  REICHERT,  M.D., 

Professor  of  Physiology,  University   of 
Pennsylvania. 


HENRY  SEW  ALL,  Ph.  D.,  M.D.. 

bia   University.    N.    Y.    (College   of  |  Professor  of  Physiology.  Medical  lleparfr 

Physicians  and  Surgeons).  '  ment.  University  of  Denver. 

"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  f,uh]ec\.s."  —  London  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  stilus  of  the  science  of  physiology  in  the  Eng- 
lish language." — American  yournal  of  the  Medical  Sciences. 


8  IV.   B.   SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEU- 
.  TICS.  For  the  Use  of  Practitioners  and  Students.  Edited  by 
James  C.  Wilson,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Jefferson  Medical  College.  One  handsome  octavo 
volume  of  1326  pages.  Illustrated.  Prices;  Cloth,  ^7.00  net;  Sheep  or 
Half- Morocco,  $8.00  net. 

The  arrangement  of  this  volume  has  been  based,  so  far  as  possible,  upon 
modern  pathologic  doctrines,  beginning  with  the  intoxications,  and  following 
with  infections,  diseases  due  to  internal  parasites,  diseases  of  undetermined 
origin,  and  finally  the  disorders  of  the  several  bodily  systems — digestive,  re- 
spiratory, circulatory,  renal,  nervous,  and  cutaneous.  It  was  thought  proper  to 
include  also  a  consideration  of  the   disorders  of  pregnancy. 

The  articles,  with  two  exceptions,  are  the  contributions  of  American  writers. 
Written  from  the  stnndpoint  of  the  practitioner,  the  aim  of  the  work  is  to  facili- 
tate the  application  of  knowledge  to  the  prevention,  the  cure,  and  the  allevia- 
tion of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of 
the  book — Applied  Therapeutics — to  indicate  the  course  of  treatment  to  be 
pursued  at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used 
at  one  time  or  another. 

The  list  of  contributors  comprises  the  names  of  many  who  have  acquired  dis- 
tinction as  practitioners  and  teachers  of  practice,  of  clinical  medicine,  and  of 
the  specialties. 

tOSTRIBUTORS : 


Dr.  I.  E.  Atkinson,  Ealtimore,  Md. 
Sanger  Brown,  Chicago,  til. 
John  B.  Chapin,  Philadelphia,  Pa. 
William  C  Dabney,  Charlottesville,  Va. 
John  Chalmers  DaCosta,  Philada.,  Pa. 
I.  N.  Uanforth,  Chicago,  III. 
John  L.  Dawson,  Jr.,  Charleston,  S.  C. 
F.  X.  Dercum,  Philadelphia.  Pa. 
George  Dock,  Ann  Arbor,  Mich. 
Robert  T.   Edes,  Jamaica  Plain.  Mass. 
Augustus  A.  Eshner,  Philadelphia,  Pa. 
1.  T.  Eskridge,  Denver,  Col. 
F.  Forchheimer,  Cincinnafi,  O. 
Carl  Frese,  Philadelphia,  Pa. 
Edwin  E.  Graham,  Philadelphia,  Pa. 
John  Guiteras,  Philadelphia,  Pa. 
Frederick  P.  Henry,  Philadelphia,  Pa. 
Guy  Hinsdale,  Philadelphia,  P.t. 
Orviile  Horwitz,  Philadelphia,  Pa. 
W.  W.  Johnston,  Washington,  D.  C. 
Ernest  Laplace,  Philadelphia,  Pa. 
A.  Laveran,  Pans,  France. 


Dr.  James  Hendrie  Lloyd,  Philadelphia,  Pa. 
John  Noland  Mackenzie,  Baltimore,  Md. 
J.  W.  McLaughlin,  Austin,  Texas. 
A.  Lawrence  Mason,  Boston,  Mass. 
Charles  K.  Mills,  Philadelphia,  Pa. 
John  K.  Mitchell.  Philadelphia,  Pa. 
\V.  P.  Northrup,  New  York  City. 
Williain  Osier,  Baltimore,  Md. 
Frederick  A.  Packard,  Philadelphia,  Pa. 
Theophilus  Parvin,  Philadelphia,  Pa. 
Beaven  Kake,  London,  England. 
E.  O.  Shakespeare,  Philadelphia,  Pa. 
Wharton  Sinkler,  Philadelphia,  Pa. 
Louis  Starr,  Philadelphia,  Pa. 
Henry  W.  Stelwagon,  Philadelphia,  Pa. 
James  Stewart,  Montreal,  Canada. 
Charles  G.  Stockton,  Buffalo,  N.  Y. 
James  Tyson,  Philadelphia,  Pa. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich. 
James  T.  Whittaker,  Cincinnati,  O. 
J.  C.  Wilson,  Philadelphia,  Pa. 


"As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  of 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician." — Chicago  Clinical  JRevieiu. 

"The  whole  field  of  medicine  has  been  well  covered.  The  work  is  thoroughly  practical, 
and  while  it  is  intended  for  practitioners  and  students,  it  is  a  better  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful  " — The  Indian  Lancet. 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  Edited  by 
Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dickinson,  M.'D. 
One  handsome  octavo  volume  of  over  looo  pages,  with  nearly  900  colored 
and  half-tone  illustrations.  Prices :  Cloth,  ^7.00  net ;  Sheep  or  Half 
Morocco,  ;^8.oo  net. 

The  advent  of  each  successive  volume  of  the  series  of  the  American  Text- 
Books  has  been  signalized  by  the  most  flattering  comment  from  both  the  Press 
and  the  Profession.  The  high  consideration  received  by  these  text-books,  and 
their  attainment  to  an  authoritative  position  in  current  medical  literature,  have 
been  matters  of  deep  international  interest,  which  finds  its  fullest  expression  in 
the  demand  for  these  publications  from  all  parts  of  the  civilized  world. 

In  the  preparation  of  the  "American  Text-Book  of  Obstetrics"  the 
editor  has  called  to  his  aid  proficient  collaborators  whose  professional  prominence 
entitles  them  to  recognition,  and  whose  disquisitions  exemplify  Practical 
Obstetrics.  While  these  writers  were  each  assigned  special  themes  for  dis- 
cussion, the  correlation  of  the  subject-matter  is,  nevertheless,  such  as  ensures 
logical  connection  in  treatment,  the  deductions  of  which  thoroughly  represent 
the  latest  advances  in  the  science,  and  which  elucidate  the  best  vtodern  methods 
of  procedure. 

The  more  conspicuous  feature  of  the  treatise  is  its  wealth  of  illustrative 
matter.  The  production  of  the  illustrations  had  been  in  progress  for  several 
years,  under  the  personal  supervision  of  Robert  L.  Dickinson,  M.  D.,  to  whose 
artistic  judgment  and  professional  experience  is  due  the  most  sumptuously 
illustrated  work  of  the  period.  By  means  of  the  photographic  art,  combined 
with  the  skill  of  the  artist  and  draughtsman,  conventional  illustration  is  super- 
seded by  rational  methods  of  delineation. 

Furthermore,  the  volume  is  a  revelation  as  to  the  possibilities  that  may  be 
reached  in  mechanical  execution,  through  the  unsparing  hand  of  its  publisher. 


CODTTRIBUTORS : 


Dr.  James  C.  Cameron. 
Edward  P.  Davis. 
Robert  L.  Dickinson. 
Charles  Warrington  Earle. 
James  H.  Eiheridge. 
Henry  J.  Ciarricues. 
Barton  Cooke  Hirst. 
Charles  Jewett. 


Dr.  Howard  A.  Kelly. 
Richard  C.  Norris. 
Chauncey  D.  Palmer. 
TheophiUis  Parvin. 
George  A.  Piersol. 
Edward  Reynolds. 
Henry  Schwarz. 


"  At  first  glance  we  are  overwhelmed  by  the  magnitude  of  this  work  in  several  respects, 
viz.  :  First,  by  the  size  of  the  volume,  then  by  the  arr.iy  of  eminent  teachers  in  this  depart- 
ment who  have  taken  part  in  its  production,  then  by  the  profuseness  and  character  of  the 
illustrations,  and  last,  but  not  least,  the  conciseness  and  clearness  with  which  the  text  is  ren- 
dered This  is  an  entirely  new  composition,  embodying  the  highest  knowledge  of  the  art  as 
it  stands  to-day  by  authors  who  occupy  the  fnmt  rank  in  their  specialty,  and  there  are  many 
of  them.  We  cannot  turn  over  these  pages  without  being  struck  by  the  superb  illustrations 
which  adorn  so  many  of  them.  We  are  confident  that  this  most  practical  work  will  find 
instant  appreciation  by  practitioners  as  well  as  students." — New  Yor/;  Medical  Times. 

Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  1  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers. 

With  profound  respect  I  am  sincerely  yours,  Ai-KX.  J.  C.  Skene. 


PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  William  Pepper,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal- octavo  volumes  of  about 
looo  pages  each,  with  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume  :  Cloth,  ^5.00  net ;  Sheep  or  Half-Morocco,  ^6.00  net. 


VOLilIME  I.  CONTAINS: 


Hygiene. — Fevers  (Ephemeral,  Simple  Con- 
tinued, Typhus,  Typhoid,  Epidemic  Cerebro- 
spinal Meningitis,  and  Relapsing). — Scarla- 
tina, Measles,  Rotheln,  Variola,  Varioloid, 
Vaccinia, Varicella,  Mumps, Whooping-cough, 
Anthrax,  Hydrophobia,  Trichinosis,  Actino- 


mycosis, Glanders,  and  Tetanus. — Tubercu- 
loois,  Scrofula,  Syphilis,  Diphtheria,  Erysipe- 
las, Malaria,  Cholera,  and  Yellow  Fever. — 
Nervous,  Muscular,  and  Mental  Diseases  etc. 


VOtlJME   II.  CONTAINS! 


Urine  (Chemistry  and  Microscopy). — Kid- 
ney and  Lungs. — Air-passages  (Larynx  and 
Bronchi)  and  Pleura. — Pharynx,  CEsophagus, 
Stomach  and  Intestines  (including  Intestinal 
Parasites),  Heart,  Aorta,  Arteries  and  Veins. 


— Peritoneum,  Liver, and  Pp.ncreas. — Diathet- 
ic Diseases  (Rheumatism,  Rheumatoid  Ar- 
thritis, Gout,  Lithsemia,  and  Diabetes.) — 
Blood  and  Spleen. — Inflammation,  Embolism, 
Thrombosis,  Fever,  and  Bacteriology. 


The  articles  are  not  written  as  though  addressed  to  student'^  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  are  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 


CONTRIBUTORS : 


Dr.  J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  H,  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
V/illiam  Osier,  Baltimore. 


Dr.  William  Pepper,  Philadelphia. 
W.  Oilman  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whiltaker,  Cincinnati. 
James  C.  Wilson,  Philadeiphia. 
Hontfo  C.  Wood,  Philadelphia. 


"  We  reviewed  the  first  volume  of  this  work,  and  said  :  '  It  is  undoubtedly  one  ol  the  best 
text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the  second 
and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  is,  in  our 
opinion,  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
bound.    It  is  a  model  of  what  the  modern  text-book  should  be." — rfew  York  Medical  yournal. 

"  A  library  upon  modern  medical  art.  The  work  must  promote  the  wider  difl'usion  of 
sound  knowledge." — American  Lane*. 

"  A  trusty  counsellor  for  the  practitioner  oi-  senior  student,  on  which  he  may  implicitly 
'ely.'  — Edinburgh  Medical  yournal. 


CATALOGUE    OF  MEDICAL    WORKS.  II 

*AN  AMERICAN  TEXT-BOOK  OF  SURGERY.  Edited  by  Wil- 
liam W.  Keen,  M.  D.,  LL.D.,  and  J.  William  White,  M.  D.,  Ph.  D. 
Forming  one  handsome  royal  octavo  volume  of  1230  pages  (10x7  inches), 
with  496  wood-cuts  in  text,  and  37  colored  and  halftone  plates,  many  of 
them  engraved  from  original  photographs  and  drawings  furnished  by  the 
authors.     Price  :  Cloth,  ^7.00  net;  Sheep  or  Half  Morocco,  gS.oo  net. 

THIRD  EDITION.  THOROUGHLY  REVISED. 

in  the  present  edition,  among  the  new  topics  introduced  are  a  full  considera- 
tion of  serum-theiapy  ;  leucocytosis  ;  post-operative  insanity;  the  use  of  dry  heat 
at  high  tem|)eratures  ;  Kronlein's  method  of  locating  the  cerebral  fissures; 
Hoffa's  and  I.orenz's  operations  of  congenital  dislocations  of  the  hip;  Allis's  re- 
searches on  dislocations  of  the  hip-joint ;  lumbar  puncture  ;  the  forcible  reposi- 
tion of  the  spine  in  Pott's  disease ;  the  treatment  of  exophthalmic  goiter ;  the 
surgery  of  typhoid  fever;  gastrectomy  and  other  operations  on  the  stomach; 
new  methodsof  operating  upon  the  intestines;  the  use  of  Kelly's  rectal  specula; 
the  surgery  of  the  ureter;  Schleich's  infiltration-method  and  the  use  of  eucain 
for  local  anesthesia;  Krause's  method  of  skin-grafting;  the  newer  metiiods  of 
disinfecting  the  hands;  the  use  of  gloves,  etc.  The  sections  on  Appendicitis, 
on  Fractures,  and  on  Gynecological  Operations  have  been  revised  and  enlarged. 
A  considerable  number  of  new  illustrations  have  been  added,  and  enhance  the 
value  of  the  work. 

The  text  of  the  entire  book  has  been  submitted  to  all  the  authors  for  their 
mutual  criticism  and  revision — an  idea  in  book-making  that  is  entirely  new  and 
original.  The  book  as  a  whole,  therefore,  expresses  on  all  the  important  sur- 
gical topics  of  the  day  the  consensus  of  opinion  of  the  eminent  surgeons  who 
have  joined  in  its  preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations.  Very 
many  of  them  are  original  and  faithful  reproductions  of  photographs  taken 
directly  from  patients  or  from  specimens, 

CONTKIBITTORS : 


Dr.  Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  W.  Keen,  Philadelphia. 
Charle.s  B    Nancrede,  Ann  Arbor.  Mich. 
Ros.well  Park.  Buffalo,  New  York. 
Lewis  S.  Pilcher.  New  York. 


Dr.  Nicholas  Senn,  Chicago. 

Francis  J.  Shepherd,  Montreal,  Canada. 

Lewis  A.  Stimson,  New  York. 

J.  Collins  Warren,  I'oston. 

J.  William  White,  Philadelphia. 


"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 

Personally,  f  should  not  mind  it  being  called  THE  Tf.xt-Kook  (instead  of  A  Text- Rook), 
for  1  know  ot  no  single  volume  which  contains  so  readable  and  complete  an  account  of  the 
science  and  art  of  Surgery  as  this  does." — Edmunij  Owen,  K.  R.  C.  S.,  Member  of  the  Board 
nf  Examiners  of  the  Royal  College  0/  Surgeons,  hntrmna 


12  IV.   B.    SAUNDERS' 


*  AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND    SURGICAL,  for  the  use  of  Students  and  Practitioners. 

Edited  by  J.  M.  Baluy,  M.  D.  Forming  a  handsome  royal-octavo  volume 
of  718  pages,  with  341  illustrations  in  the  text  and  38  colored  and  half- 
tone plates.     Prices  :  Cloth,  ^6.00  net;  Sheep  or  Half-Morocco,  $7.00  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
understanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  work,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  slili  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  jiicture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

In  the  revised  edition  much  new  material  has  been  added,  and  some  of  the 
old  eliminated  or  modified.  More  than  forty  of  the  old  illustrations  have  been 
replaced  by  new  ones,  which  add  very  materially  to  the  elucidation  of  the 
text,  as  they  picture  methods,  not  specimens.  The  chapters  on  technique  and 
after-treatment  have  been  considerably  enlarged,  and  the  portions  devoted  to 
plastic  work  have  been  so  greatly  improred  as  to  be  practically  new.  Hyste- 
rectomy has  been  rewritten,  and  all  the  descriptions  of  operative  procedures 
have  been  carefully  revised  and  fully  illustrated. 


CONTRIBrTORS : 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
H.  Etheridge. 
William  Goodell. 


Wil 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"The  most  notable  contribution  to  gynecological  literature  since  1887 and  the  most 

complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
yournal. 

"  A  thoroughly  modern  text-book,  and  gives  reliable  and  well-tempered  advice  and  in- 
struction."— Edinburgh  Medical  Journal. 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship."— .,4««a/.f  0/  Surgery. 

"  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  yournal  of  Medical  Sciences. 


CATALOGUE    OF  MEDICAL    WORKS. 


13 


*AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  Starr,  M.  D., 
assisted  by  THOMPSON  S,  Westcott,  M.  D.  In  one  handsome  r©yal-8vr> 
volume  of  1244  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.    Net  Prices:  Cloth,  $'j.oo;  Sheep  or  Half-Morocco,  ^8.00. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  poediatrists,  representing  collectively  the  teachmgs  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formul^e  and  therapeutic  procedures. 

In  this  new  edition  the  whole  subject  matter  has  been  carefully  revised;  new 
articles  added,  some  original  papers  emended,  and  a  number  entirely  rewritten. 
The  new  articles  include  "Modified  Milk  and  Percentage  Milk-Mixtures," 
"  Lithemia,"  and  a  section  on  "  Orthopedics."  Those  rewritten  are  "  Typhoid 
Fever,"  "Rubella,"  "Chicken-pox,"  "Tuberculous  Meningitis,"  "Hydroceph- 
alus," and  "Scurvy;"  while  extensive  revision  has  been  made  in  "Infant 
Feeding,"  "  Measles,"  "  Diphtheria,"  and  "  Cretinism."  The  volume  has  thus 
been  much  increased  in  size  by  the  introduction  of  fresh  material. 

CONTRIBUTORS  1 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
D.ivid  Bovaird,  ^few  York. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Chuich,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Ciirtin,  Philadelphia 
J.  M.  DaCos'a,  Philadelphia. 
I.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweinitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 

t  Henry  Fruitnight,  New  York. 
P.  Crozer  Griffith,  Philadelphia. 
.  A.  Hardaway.  St.  Louis. 
M.  P    Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit 
Henry  Koplik.  New  York. 


Dr.  Thomas  S.  Latimer,  Baltimore. 

Albert  R.  Leeds,  Hoboken,  N.  J. 

J.  Hendrie  Lloyd,  Philadelphia. 

George  Roe  Lockwood,  New  York. 

Henry  M.  Lyman,  Chicago. 

Francis  T.  Miles,  Baltimore. 

Charles  K    Mills,  Philadelphia. 

James  E    Moore,  Minneapolis. 

F.  Gordon  Morrill,  Boston. 

John  H.  Musser,  Philadelphia. 

Thomas  R.  Neilson,  Philadelphia. 

W.  P.  Northrup,  New  York. 

William  Osier,  Baltimore. 

Frederick  A.  Packard,  Philadelphia. 

William  Pepper,  Philadelphia. 

P'rederick  Peterson,  New  York. 

W.  T.  Plant,  Syracuse,  New  York 

William  .\1.  Powell.  Atlantic  City. 

B.  K.  Rachford,  Cincinnati. 

B.  Alexander  Randall,  Philadelphia. 

Edward  O.  Shakespeare,  Philadelphia 

F.  C.  Shattuck,  Boston. 

J.  Lewis  Smith,  New  York. 

Louis  Starr,  Philadelphia. 

M.  Allen  Starr,  New  York. 

Charles  W.  Townsend,  Boston. 

lames  Tyson,  Philadelphia. 

W.  S.  Thayer,  Baltimore. 

Victor  C.  Vaughan,  Ann  Arbor,  Mich 

Thompson  S.  Westcott,  Philadelphia. 

Henry  R.  Wharton,  Philadelphia. 

J    William  White,  Philadelphia. 

J.  C.  Wilson,  Philadelphia. 


H 


IV.   B.   SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  GENITO-URINARY  AND 
SKIN  DISEASES.  By  47  Eminent  Specialists  and  Teachers.  Edited 
by  L.  Bolton  Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  Uni- 
versity and  Bellevue  Hospital  Medical  College,  New  York ;  and  W.  A. 
Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Missouri  Medical 
College.  Imperial  octavo  volume  of  1229  pages,  with  300  engravings  and 
20  full-page  colored  plates.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
$8.00  net. 

This  addition  to  the  series  of  "  American  Text-Books,"  it  is  confidently  be- 
lieved, will  meet  the  requirements  of  both  students  and  practitioners,  giving,  as 
it  does,  a  comprehensive  and  detailed  presentation  of  the  Diseases  of  the 
Genito-Urinary  Organs,  of  the  Venereal  Diseases,  and  of  the  Affections  of  the 
Skin. 

Having  secured  the  collaboration  of  well-known  authorities  in  the  branches 
represented  in  the  undertaking,  the  editors  have  not  restricted  the  contributors 
ii.  regard  to  the  particular  views  set  forth,  but  have  offered  every  facility  for  the 
free  expression  of  their  individual  opinions.  The  work  will  therefore  be  found 
to  be  original,  yet  homogeneous  and  fully  representative  of  the  several  depart- 
ments of  medical  science  with  which  it  is  concernea. 


CONTRIBUTORS : 


Dr.  Chas.  W.  Allen;  New  York. 
I.  E.  Atkinson,  Baltimore. 
L   Bolton  Bangs,  New  York. 
P.  R.  Bolton,  New  York. 
Lewis  C.  Bosher,  Richmond,  Va. 
John  T.  Bowen,  Boston. 
J.  Abbott  Cantrell.  Philadelphia. 
William  T.  Corlett,  Cleveland,  Ohio. 
B.  Farquhar  Curtis,  New  York. 
Condict  W.  Cutler,  New  York. 
Isadore  Dyer,  New  Orleans. 
Christian   Fenger,  Chicago. 
John  A.  Fordyce,  New  York. 
Eugene  Fuller,  New  York. 
R.  H.  Greene,  New  York. 
Joseph  Grindon,  St.  Louis. 
Graeme  ^L  Hammond,  New  York. 
W.  A.  Hardaway,  St.  Louis. 
M.  B.  Hartzell,  Philadelphia. 
Louis  Heitzmann,  New  York. 
James  S.  Howe,  Boston. 
George  T.  Jackson,  New  York. 
Abraham  Jacobi.  New  York. 
James  C.  lohnslon.  New  York. 


Dr.  Hermann  G.  Klotz,  New  York. 
J.  H.  Linsley,  Burlington,  Vt, 
G.  F.  Lydston,  Chicago. 
Hartwell  N.  Lyon.  St.  Louis. 
Edward  Martin,  Philadelphia. 
D.  G.  Montgomery,  San  Francisco. 
James  Pedersen,  New  York. 
S.  Pollitzer,  New  York. 
Thomas  R.  Pooley,  New  York. 
A.  R.  Robinson,  New  York. 
A.  E.  Rtgensburger,  San  Francisco. 
Francis  J.  Shepherd,  Montreal,  Can. 
S.  C.  Stanton,  Chicago,  ill. 
Emmanuel  J.  Stout,  iPhiladelphia. 
Alonzo  E.  Taylor    Philadelphia. 
Robert  W.  Taylor,  New  York. 
Paul  Thorndike,  Boston. 
H.  Tuholske,  St.  I^ouis. 
Arthur  Van  Harlingen,  Philadelphia. 
Francis  S.  Watson,  Boston, 
J.  William  White,  Philadelphia. 
J.  McF.  Wiufield,  Brooklyn. 
Alfred  C.  Wood,  Philadelpma. 


"This  voluminous  work  is  thoroughly  up  to  date,  and  the  chapters  on  genito-unnarv  ois- 
eases  are  especially  valuable.  The  illustrations  are  fine  and  are  mostly  original.  The  section 
on  dermatology  is  concise  and  in  every  way  admirable."— y<;«r«a/  of  the  American  Medical 
Association. 

"This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of  'American  Text- 
Books.'  The  list  of  contributors  represents  an  extraordinary  array  of  talent  and  extended 
experience.  The  book  will  easily  take  the  place  in  comprehensiveness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  hitherto  been  necessary  to  a 
well-equipped  library." — New  York  Polvclinic. 


CATALOGUE    OF  MEDICAL    WORKS. 


15 


*  AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE, 
EAR,  NOSE,  AND  THROAT.    Edited  by  George  E.  de  Schweinitz, 

A.  M.,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical  College;  and 

B.  Alexander  Randall,  A.  M.,  M.  D.,  Clinical  Professor  of  Diseases  of 
the  Ear,  University  of  Pennsylvania.  One  handsome  imperial  octavo 
volume  of  1251  pages;  766  illustrations,  59  of  them  colored.  Prices: 
Clot'i.,  S7.00  net;  Sheep  or  Half- Morocco,  $8.00  net. 

Just  Issued. 

The  present  work  is  the  only  book  ever  published  embracing  diseases  of  the 
intimately  related  organs  of  the  eye,  ear,  nose,  and  tHroat.  Its  special  claim 
to  favor  is  based  on  encyclopedic,  authoritative,  and  practical  treatment  of  the 
subjects. 

Each  section  of  the  book  has  been  entrusted  to  aa  author  who  is  specially 
identified  with  the  subject  on  which  he  writes,  and  who  therefore  presents  his 
case  in  the  manner  of  an  expert.  Uniformity  is  secured  and  overlapping  pre- 
vented by  careful  editing  and  by  a  system  of  cross-references  which  forms  a 
special  feature  of  the  volume,  enabling  the  reader  to  come  into  touch  with  all 
that  is  said  on  any  subject  in  different  portions  of  the  book. 

Particular  emphasis  is  laid  on  the  most  approved  methods  of  treatment,  so 
that  the  book  shall  be  one  to  which  the  student  and  practitioner  can  refer  for 
information  in  practical  work.  Anatomical  and  physiological  problems,  also, 
are  fully  discussed  for  the  benefit  of  those  who  desire  to  investigate  the  more 
abstruse  problems  of  the  subject. 


CONTRIBUTORS : 


.Dr.  Henry  A.  Alderton,  Brooklyn. 
Harrison  .411en,  Philadelphia. 
Frank  Allport,  Chicago. 
Morris  J.  Asch.  New  York. 
S.  C.  Ayres,  Cincinnati. 
R.  O.  Beard,  Minneapolis. 
Clarence  J.  Blake,  Boston. 
Arthur  .A..  Bliss,  Philadelphia. 
Albert  P.  Brub;iker,  Philadelphia. 
J.  H.  Bryan,  Washington,  D.  C. 
Albert  H.  Buck,  New  York. 
F.  Buller,  Montreal,  Can. 
Swan  M.  Burnett,  Washington,  D   C. 
I"  lemming  Carrow,  Ann  Arbor,  Mich. 
V/.  E.  Casselberry,  Chicago. 
Colman  W.  Cutler,  New  York. 
Edward  B.  Dench,  New  York. 
William  S.  Dennett,  New  York. 
George  E.  de  Schweinitz,  Philadelphia. 
Alexander  Duane,  New  York. 
John  W.  Farlow,  Boston,  Mass. 
Walter  J    freeman,  Philadelphia. 
H.  Giffbrd,  Omaha,  Neb. 
W.  C.  Glasgow,  St.  Louis. 
T-  Orne  Green,  Boston. 
Ward  A.  Holden,  New  York. 
Christian  R.  Holmes,  Cincinnati. 
William  E.  Hopkins,  San  Francisco. 
F.  C  Hotz,  Chicago. 
Lucien  Howe,  Bunalo,  N.  Y. 


Dr.  Alvin  A.  Hubbell,  Buffalo,  N.  Y. 
Edward  Jackson,  Philadelphia. 
J.  Ellis  Jennings,  St.  Louis. 
Herman  Knapp,  New  York, 
("has.  W.  Kollock,  Charleston,  S.  C. 
\'i.  A   Leland,  Boston. 
J.  A.  LippiHcott,  Pittsburg.  Pa. 
O.  Hudson  Makuen,  Philadelphia. 
Tohn  H.  McCoUom,  Boston. 
H.  G.  Miller,  Providence,  R.  L 
B.  L.  Jlilliken,  Cleveland,  Ohio. 
F'.obert  C.  Myles,  New  York, 
James  E.  Newcomb,  New  York. 
R.  J.  Phillips,  Philadelphia. 
George  A.  Piersol,  Philadelphia. 
W.  P.  Porcher,  Ch.irleston.  S.  C. 
B.  Alex.  Randall,  Philadelphia. 
Robert  L.  Randolph,  Baltimore. 
John  O.  Roe,  Rochester,  N.  Y. 
Charles  E.  de  M.  Sajous,  Philadelphia. 
J.  E.  Sheppard,  Brooklyn,  N.  Y. 
E.  L.  Shurly.  Detroit,  Mich. 
William  M.  Sweet,  Philadelphia. 
Samuel  Theobald.  Baltimore,  Md. 
A.  G.  Thomson,  Philadelphia. 
Clarence  A.  Veasey,  Philadelphia. 
John  E.  Weeks,  New  York. 
Casey  A.  Wood,  Chicago,  111. 
Jonathan  Wright,  Brooklyn. 
H.  V.  Wiirdemann,  Milwaukee,  Wit. 


i6 


IV.    B.   SAUNDERS' 


*AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SUR- 
GERY. A  Yearly  Digest  of  Scientific  Progress  and  Authoritative 
Opinion  in  all  branches  of  Medicine  and  Surgery,  drawn  from  journals> 
monographs,  and  text-books  of  the  leading  American  and  Foreign  authors 
and  investigators.  Collected  and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  George  M.  Gould,  M.  D.  Volumes  for  1896,  '97, 
'98,  and  '99  each  a  handsome  imperial  octayo  volume  of  about  1200  pages. 
Prices :  Cloth,  $6.50  net ;  Half-Morocco,  ^7.50  net.  Year- Book  for  1900  in 
two  octavo  volumes  of  about  600  pages  each.  Prices  per  volume :  Cloth, 
;^3.oo  net;   Half- Morocco,  $3.75  net. 

In  Two  Volumes.    No  Increase  in  Price. 

In  response  to  a  widespread  demand  from  the  medical  profession,  the  pub- 
lisher of  the  "American  Year- Book  of  Medicine  and  Surgery"  has  decided  to 
issue  that  well-known  work  in  two  volumes,  Vol.  I.  treating  of  General  Medi- 
cine, Vol.  II.  of  General  Surgery.  Each  volume  is  complete  in  itself,  and 
the  work  is  sold  either  separately  or  in  sets. 

This  division  is  made  in  such  a  way  as  to  appeal  to  physicians  from  a  class 
standpoint,  one  volume  being  distinctly  medical,  and  the  other  distinctly  surgi- 
cal. This  arrangement  has  a  two-fold  advantage.  To  the  physician  who  uses 
the  entire  book,  it  offers  an  increased  amount  of  matter  in  the  most  convenient 
form  for  easy  consultation,  and  without  any  increase  in  price;  while  the  man 
who  wants  either  the  medical  or  the  surgical  section  alone  secures  the  complete 
consideration  of  his  branch  without  the  necessity  of  purchasing  matter  for  which 

he  has  no  use. 

CONTBIBUTORS : 


Vol.  I. 
Dr.  Samuel  W.  Abbott.  Boston. 
Archibald  Church,  Chicago. 
Louis  A.  Duhring,  Philadelphia. 
D.  I..  Edsall,  Philadelphia. 
Alfred  Hand,  Jr.,  Philadelphia. 
M.  B.  Hartzell,  Philadelphia. 
Keid  Hunt,  Baltimore. 
Wyatt  Johnston,  Montre.il. 
Walter  Jones,  Baltimore. 
David  Riesman.  Philadelphia. 
Louis  Starr,  Philadelphia. 
Alfred  Stengel,  Philadelphia. 
A.  A.  Stevens,  Philadelphia. 
G.  N.  Stewart.  Cleveland. 
Reynold  W.  Wilcox,  New  York  City. 


Vol.  IL 
Dr.  J    Montgomery  Baldy,  Philadelphia. 
Charles  H.  Burnett,  Philadelphia. 
J.  Chalmers  DaCosta.  Philadelphia. 
W.  A.    N.  Dorland,  Philadelphia. 
Virgil  P.  Gibney,  New  York  City. 
C.  H.  Hamann,  Cleveland. 
Howard  F.  Hansell,  Philadelphia. 
Barton  Cooke  Hirst,  Philadelphia. 
E.  Fletcher  Ingals,  Chicago. 
W.  W.  Keen,  Philadelphia. 
Henry  G.  Ohls,  Chicago. 
Wendell  Reber,  Philadelphia. 
J.  Hilton  Waterman,  New  York  City. 


"It  is  difficult  to  know  which  to  admire  most— the  research  and  industry  of  tne  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  \  ear-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  ...  It  is  much  mors  than  a  mere  compilation  of  abstracts  tor, 
as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the  advan- 
tage of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers  tully 
qualified  to  perform  these  tasks.  ...  It  is  emphatically  a  book  which  should  find  a  place  in 
every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous  Jahrbucner 
of  Germany." — London  Lancet. 


CATALOGUE    OF  MEDICAL    WORKS.  1 7 

*  ANOMALIES  AND  CURIOSITIES  OF  MEDICINE.  By  George 
M.  Gould,  M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collec- 
tion of  are  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an  ex- 
haustive research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  imperial  octavo 
volume  of  968  pages,  with  295  engravings  in  the  text,  and  12  full-page 
plates.     Cloth,  $3.00  net ;   Half-Morocco,  S4.00  net. 

POPULAR  EDITION  REDUCED  FROM  $6.00  to  $3.00. 

In  view  of  the  great  success  of  this  magnificent  work,  the  publisher  has  decided 
to  issue  a  "  Popular  Edition"  at  a  price  so  low  that  it  may  be  procured  by  every 
student  and  practitioner  of  medicine.  Notwithstanding  the  great  reduction  in 
price,  there  will  be  no  depreciation  in  the  excellence  of  typography,  paper,  and 
binding  that  characterized  the  earlier  editions. 

Several  years  of  exhaustive  research  have  been  spent  by  the  authors  in  the 
great  medical  libraries  of  the  United  States  and  Europe  in  collecting  the  mate- 
rial for  this  work.  Medical  literature  of  all  ages  and  all  languages  has 
been  carefully  searched,  as  a  glance  at  the  Bibliographic  Index  will  show.  The 
facts,  which  will  be  of  extreme  value  to  the  author  and  lecturer,  have  been 
arranged  and  annotated,  and  full  reference  footnotes  given. 

"One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far  as 
we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for  the 
medical  profession  has  this  volume  value  :  it  will  serve  as  a  book  of  reference  for  all  who  are 
interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical  yoiir- 
nal. 

NERVOUS  AND  MENTAL  DISEASES.  By  Archibald  Church, 
M.  D.,  Professor  of  Clinical  Neurology,  Mental  Diseases,  and  Medical 
Jurisprudence,  Northwestern  University  Medical  School;  and  Fredkrick 
Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases,  Woman's  Medi- 
cal College,  New  York.  Handsome  octavo  volume  of  843  pages,  with 
over  300  illustrations.     Prices:    Cloth,  $5.00  net;    Half- Morocco,  $6.00 

net. 

Second  Edition. 

This  book  is  intended  to  furnish  students  and  practitioners  with  a  practical, 
working  knowledge  of  nervous  and  mental  diseases.  Written  by  men  of  wide 
experience  and  authority,  it  presents  the  many  recent  additions  to  the  suiyect. 
The  book  is  not  iilied  with  an  extended  dissertation  on  anatomy  and  pathology, 
but,  treating  these  [loints  in  connection  with  special  conditions,  it  lays  |)articular 
stress  on  methods  of  examination,  diagnosis,  and  treatment.  In  this  respect  the 
work  is  unusually  complete  and  valuable,  laying  down  the  definite  courses  of 
procedure  which  the  authors  have  found  to  be  most  generally  satisfactory. 

"The  work  is  an  epitome  of  what  is  to-day  known  of  nervous  diseases  prepared  for  the 
student  and  practitioner  in  the  light  of  the  author's  experience  .  .  .  We  believe  that  no  work 
presents  the  difficult  subject  of  insanity  in  such  a  reasonable  and  readable  way." — Chicago 
Medical  Recorder. 


1 8  W.    B.    SAUNDERS' 


DISEASES  OF  THE  NOSE  AND  THROAT.     By  D.  Braden  Kyle, 

M.  D.,  Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medi- 
cal College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital.  Octavo  volume  of  646  pages,  vvith  over 
150  illustrations  and  6  lithographic  plates.  Cloth,  $4.00  net;  Half-Mo- 
rocco, $5.00  net. 

Just  Issued. 

This  book  presents  the  subject  of  Diseases  of  the  Nose  and  Throat  ui  as  con- 
cise  a  manner  as  is  consistent  with  clearness,  keeping  in  mind  the  needs  of  the 
student  and  general  practitioner  as  well  as  those  of  the  specialist.  Tiie  arrange- 
ment and  classification  are  based  on  modern  pathology,  and  the  pathological 
views  advanced  are  supported  by  drawings  of  microscopical  sections  made  in  the 
author's  own  laboratory.  These  and  the  other  illustrations  are  particularly  fine, 
being  chiefly  original.  With  the  practical  purpose  of  the  book  in  mind,  ex- 
tended consideration  has  been  given  to  details  of  treatment,  each  disease  being 
considered  in  full,  and  definite  courses  being  laid  down  to  meet  special  condi- 
tions and  symptoms. 

"  It  is  a  thorough,  full,  and  systematic  treatise,  so  classified  and  arranged  as  greatly  to  facili- 
tate the  teaching  of  laryngology  and  rhinology  to  classes,  and  must  prove  most  convenient 
and  satisfactory  as  a  reference  book,  both  for  students  and  practitioners." — International 
Medical  Magazine. 

THE  HYGIENE  OF  TRANSMISSIBLE  DISEASES  :  their  Causa- 
tion, Modes  of  Dissemination,  and  Methods  of   Prevention.     By 

A.  C.  Abbott,  M.  D.,  Professor  of  Hygiene  in  the  University  of  Pennsyl- 
vania; Director  of  the  Laboratory  of  Hygiene.  Octavo  volume  of  311 
pages,  with  charts  and  maps,  and  numerous  illustrations.     Cloth,  $2.00  net. 


Just   Issued. 

It  is  not  the  purpose  of  this  woik  to  present  the  subject  of  Hygiene  in  the 
comprehensive  sense  ordinarily  im])lied  by  the  word,  but  rather  to  deal  directly 
with  but  a  section,  certainly  not  the  least  important,  of  the  subject — viz.,  that 
embracing  a  knowledge  of  the  preventable  specific  diseases.  The  book  aims  to 
furnish  information  concerning  the  detailed  management  of  transmissible  dis- 
eases. Incidentally  there  are  discussed  those  numerous  and  varied  factors  that 
have  not  only  a  direct  bearing  upon  the  incidence  and  suppression  of  such  dis- 
eases, but  are  of  general  sanitary  importance  as  well. 

"  The  work  is  admirable  in  conception  and  no  less  so  in  execution.  It  is  a  practical  work, 
simply  and  lucidly  written,  and  it  should  prove  a  most  helpful  aid  in  that  department  of 
medicine  which  is  becoming  daily  of  increasing  importance  and  application — namely,  prophy- 
laxis."— I'hiladcl/>liia  Medical  Journal. 

"  It  is  scientific,  but  not  too  technical  ;  it  is  as  complete  as  our  present-day  knowledge  of 
hygiene  and  sanitation  allows,  and  it  is  in  harmony  with  the  efforts  of  the  profession,  which 
are  tending  more  and  more  to  methods  of  prophylaxis.  For  the  student  and  for  the  practi- 
tioner it  is  well  nigh  indispensable." — Medical  News,  New  York. 


CATALOGUE    OF  MEDICAL    WORKS.  ig 

A  TEXT-BOOK  OF  EMBRYOLOGY,  By  John  C.  Heisler,  M.  D, 
Professor  of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia 
Octavo  volume  of  405  pages,  with  190  illustrations,  26  in  colors.  Cloth 
;?2.5o  net. 

Just  Issued. 

The  facts  of  embryology  having  acquired  in  recent  years  such  great  interest 
in  connection  with  the  teaching  and  with  the  proper  comprehension  of  human 
anatomy,  it  is  of  first  importance  to  the  student  of  medicine  that  a  concise  and 
yet  sufficiently  full  te.xt-book  upon  the  subject  be  available.  It  was  with  the 
aim  of  presenting  such  a  book  that  this  volume  was  written,  the  author,  in  his 
experience  as  a  teacher  of  anatomy,  having  been  impressed  with  the  fact  that 
students  were  seriously  handicapped  in  their  study  of  the  subject  of  embryology 
by  the  lack  of  a  text-book  full  enough  to  be  intelligible,  and  yet  without  that 
minuteness  of  detail  which  characterizes  the  larger  treatises, and  which  so  often 
serves  only  to  confuse  and  discourage  the  beginner. 

"  In  short,  the  book  is  written  to  fill  a  want  which  has  distinctly  existed  and  which  it 
definitely  meets ;  commendation  greater  than  this  it  is  not  possible  to  give  to  anything." — 
Medical  News,  New  York. 

A  MANUAL  OF  DISEASES  OF  THE  EYE.  By  Edward  Jack- 
son, A.  M.,  M.  D.,  sometime  Professor  of  Diseases  of  the  Eye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine.  i2mo,  604 
pages,  with  178  illustrations  from  drawings  by  the  author.    Cloth,  ^2.50  net. 

Jnst  Issued. 

This  book  is  intended  to  meet  the  needs  of  the  general  practitioner  of  medi- 
cine and  the  beginner  in  ophthalmology.  More  attention  is  given  to  the  condi- 
tions that  must  be  met  and  dealt  with  early  in  ophthalmic  practice  than  to  the 
rarer  diseases  and  more  difficult  operations  that  may  come  later. 

It  is  designed  to  furnish  efficient  aid  in  the  actual  work  of  dealing  with  dis- 
ease, and  therefore  gives  the  place  of  first  importance  to  the  recognition  and 
management  of  the  conditions  that  present  themselves  in  actual  clinical  work. 

LECTURES  ON  THE  PRINCIPLES  OF  SURGERY.  By  Charles 
B.  Nancrede,  M.  D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
University  of  Michigan,  Ann  Arbor.  Handsome  octavo,  398  pages,  illus- 
trated.    Cloth,  ;^2.50  net. 

Just  Issued. 

The  present  book  is  based  on  the  lectures  delivered  by  Dr.  Nancrede  to  his 
undergraduate  classes,  and  is  intended  as  a  text-book  for  students  and  a  practi- 
cal help  for  teachers.  By  the  careful  elimination  of  unnecessary  details  of 
pathology,  bacteriology,  etc.,  which  are  amply  jirovided  for  in  other  courses  of 
study,  space  is  gained  for  a  more  extended  consideration  of  the  Principles  of 
Surgery  in  themselves,  and  of  the  application  of  these  principles  to  methods 
of  practice. 


20  I'V.   B.    SAUNDERS' 


A  TEXT-BOOK  OF  PATHOLOGY.  By  Alfred  Stengel,  M.  D., 
Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Physi- 
cian to  the  Philadelphia  Hospital ;  Physician  to  the  Children's  Hospital, 
Philadelphia.  Handsome  octavo  volume  of  848  pages,  with  362  illustra- 
tions, many  of  which  are  in  colors.  Prices :  Cloth,  #4.00  net ;  Half- 
Morocco,  ^5.00  net. 

Second  Edition. 

In  this  work  the  practical  application  of  pathological  facts  to  clinical  medicine 
is  considered  more  fully  than  is  customary  in  works  on  pathology.  While  the 
subject  of  pathology  is  treated  in  the  broadest  way  consistent  with  the  size  of 
the  book,  an  effort  has  been  made  to  present  the  subject  from  the  point  of  view 
of  the  clinician.  The  general  relations  of  bacteriology  to  pathology  are  dis- 
cussed at  considerable  length,  as  the  importance  of  these  branches  deserves.  It 
will  be  found  that  the  recent  knowledge  is  fully  considered,  as  well  as  older  and 
more  widely-known  facts. 

"  I  consider  the  work  abreast  of  modern  pathology,  and  useful  to  both  students  and  prac- 
titioners. It  presents  in  a  concise  and  well-considered  form  the  essential  facts  of  general  and 
special  pathological  anatomy,  with  more  than  usual  emphasis  upon  pathological  physiology." 
— William  H.  Welch,  Frofcssor  of  PatJiology,  Joltns  Hopkins  University,  Baltimore,  Md. 

"  I  regard  it  as  the  most  serviceable  text-book  for  students  on  this  subject  yet  written  by 
an  American  author." — L.  Hkktoen,  Professor  of  Patliology,  Rush  JMedical  College, 
Chicago,  III. 

A  TEXT-BOOK  OF  OBSTETRICS.  By  Barton  Cooke  Hirst,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome  oc- 
tavo volume  of  846  pages,  with  618  illustrations  and  seven  colored  plates. 
Prices:  Cloth,  ;^5.00  net;  Half- Morocco,  ^6.00  net. 

Second  Edition. 

This  work,  which  has  been  in  course  of  preparation  for  several  years,  is  in- 
tended as  an  ideal  text-book  for  the  student  no  less  than  an  advanced  treatise 
for  the  obstetrician  and  for  general  practitioners.  It  represents  the  very  latest 
teaching  in  the  practice  of  obstetrics  by  a  man  of  extended  experience  and 
recognized  authority.  The  book  emphasizes  especially,  as  a  work  on  obstetrics 
should,  the  practical  side  of  the  subject,  and  to  this  end  presents  an  unusually 
large  collection  of  illustrations.  A  great  number  of  these  are  new  and  original, 
and  the  whole  collection  will  form  a  complete  atlas  of  obstetrical  practice. 
An  extremely  valuable  feature  of  the  book  is  the  large  number  of  refer- 
ences to  cases,  authorities,  sources,  etc.,  forming,  as  it  does,  a  valuable  bib- 
liography of  the  most  recent  and  authoritative  literature  on  the  subject 
of  obstetrics.  As  already  stated,  this  work  records  the  wide  practical  ex- 
perience of  the  author,  which  fact,  combined  with  the  brilliant  presentation 
of  the  subject,  will  doubtless  render  this  one  of  the  most  notable  books  on 
obstetrics  that  has  yet  appeared. 

"  The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the 
first  time.  The  arrangement  of  the  subject-matter,  the  foot-notes,  and  index  are  beyond 
criticism.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never 
necessary  to  re-read  a  sentence  in  order  to  grasp  its  meaning.  As  a  true  model  of  what  a 
modern  text-book  in  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's 
book  is  without  a  rival." — Neiv   York  Medical  Record. 


CATALOGUE    OF  MEDICAL    WORKS.  21 

A    TEXT-BOOK    OF    THE    PRACTICE    OF    MEDICINE.      By 

James  M.  Anders,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  College,  Philadel- 
phia. In  one  handsome  octavo  volume  of  1292  pages,  fully  illustrated. 
Cloth,  $5.50  net ;  Sheep  or  Half-Morocco,  ;^6.5o  net. 

THIRD   EDITION,  THOROUGHLY  REVISED. 

The  present  edition  is  the  result  of  a  careful  and  thorough  revision.  A  few 
new  subjects  have  been  introduced  :  Glandular  Fever,  Ether-pneumonia,  Splenic 
Anemia,  Meralgia  Paresthetica,  and  Periodic  Paralysis.  The  affections  that 
have  been  substantially  rewritten  are:  Plague,  Malta  Fever,  Diseases  of  the 
Thymus  Gland,  Liver  Cin^hoses,  and  Progressive  Spinal  Muscular  Atrophy. 
The  following  articles  have  been  extensively  revised  :  Typhoid  Fever,  Yellow 
Fever,  Lobar  Pneumonia,  Dengue,  Tuberculosis,  Diabetes  Mellitus,  Gout,  Ar- 
thritis Deformans,  Autumnal  Catarrh,  Diseases  of  the  Circulatory  System-,  more 
particularly  Hypertrophy  and  Dilatation  of  the  Heart,  Arteriosclerosis  and 
Thoracic  Aneurysm,  Pancreatic  Hemorrhage,  Jaundice,  Acute  Peritonitis,  Acute 
Yellow  Atrophy,  Hematoma  of  Duia  Mater,  and  Scleroses  of  the  Brain.  The 
preliminary  chapter  on  Nervous  Diseases  is  new,  and  deals  with  the  subject  of 
localization  and  the  various  methods  of  investigating  nervous  affections. 

"It  is  an  excellent  book — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 
— James  C.  Wilson,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  Jeffer- 
son Medical  College,  Philadelphia. 

"  The  book  can  be  unreservedly  recommended  to  students  and  practitioners  as  a  safe,  full 
compendium  of  the  knowledge  of  internal  medicine  of  the  present  day  ...  It  is  a  work 
thoroughly  modern  in  every  sense." — Medical  News,  New  York. 

DISEASES  OF  THE  STOMACH.  By  William  W.  Van  Vat.zah, 
M.  D.,  Professor  of  General  M-- Jicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic;  and  J.  Douglas  Nisbet,  M.  D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  Sys- 
tem and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674  pages, 
illustrated.     Cloth,  ^3.50  net. 

An  eminently  practical  book,  intended  as  a  guide  to  the  student,  an  aid  to  the 
physician,  and  a  contribution  to  scientific  medicine.  It  aims  to  give  a  complete 
description  of  the  modern  methods  of  diagnosis  and  treatment  of  diseases  of  the 
stomach,  and  to  reconstruct  the  pathology  of  the  stomach  in  keeping  with  the 
revelations  of  scientific  research.  The  book  is  clear,  practical,  and  complete, 
and  contains  the  results  of  the  authors'  investigations  and  of  their  extensive  ex- 
perience as  specialists.  Particular  attention  is  given  to  the  important  subject  of 
dietetic  treatment.  The  diet-lists  are  very  complete,  and  are  so  arranged  that 
selections  can  readily  be  made  to  suit  individual  cases. 

"This  is  the  most  satisfactorj'  work  on  the  subject  in  the  English  language." — Chicago 
Medical  Recorder. 

"  The  article  on  diet  and  general  medication  is  one  of  the  most  valuable  in  the  book,  and 
should  be  read  by  every  practising  physician." — Nezv  York  Medical  fournal. 


22  fV.   £.    SAUNDERS' 


SURGICAL   DIAGNOSIS    AND    TREATMENT.     By   J.  W.    Mac- 
DONALD,  M.  D.,  Edin.,  F.  R.  C.  S.,  Edin.,  Professor  of  the  Practice  of  Sur- 
gery and  of  Clinical  Surgery  in  Hamline  University ;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.     Handsome  octavo  volume  of  800 
pages,  profusely  illustrated.     Cloth,  $5.00  net;  Half-Morocco,  $6.00  net. 
This  work  aims  in  a  comprehensive  manner  to  furnish  a  guide  in  matters  of 
surgical  diagnosis.     It  sets  forth  in  a  systematic  way  the  necessities  of  examina- 
tions and  the  proper  methods  of  making  them.     The  various  portions  of  the 
body  are  then  taken  up  in  order  and  the  diseases  and  injuries  thereof  succinctly 
considered  and  the  treatment  briefly  indicated.     Practically  all  the  modern  and 
approved  operations  are  described  with  thoroughness  and  clearness.     The  work 
concludes  with  a  chapter  on  the  use  of  the  Rontgen  rays  in  surgery. 

"  The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  book  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cincinnati  La?icei- Clinic. 

PATHOLOGICAL  TECHNIQUE.     A  Practical  Manual  for  Laboratory 
Work  in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post- Mortem  Technique  and  the  Performance  of  Autopsies.     By  Frank 
B.  Mallory,  A.  M.,  M.  D.,  Assistant   Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston  ;  and  James  H.  Wright,  A.  M.,  M.  D., 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston.     Oc- 
tavo volume  of  396  pages,  handsomely  illustrated.     Cloth,  ^2.50  net. 
This  book  is  designed  especially  for  practical  use  in  pathological  laboratories, 
both  as  a  guide  to  beginners  and  as  a  source  of  reference  for  the  advanced.    The 
book  will  also  meet  the  wants  of  practitioners  who  have  opportunity  to  do  general 
pathological  work.     Besides  the  methods  of  post-mortem  examinations  and  of 
bacteriological    and   histological   investigations    connected    with    autopsies,   the 
special  methods   employed  in  clinical  bacteriology  and  pathology  have  been 
fully  discussed. 

"  One  of  the  most  complete  works  on  the  subject,  and  one  which  should  be  in  the  library 
of  every  physician  who  hopes  to  keep  pace  with  the  great  advances  made  in  pathology." — 
yournal  of  American  Medical  Association. 

THE  SURGICAL  COMPLICATIONS  AND  SEQUELS  OF  TY- 
PHOID  FEVER.     By  Wm.  W.  Kekn,  M.  D.,  LL.D.,  Professor  of  the 
Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College, 
Philadelphia.     Octavo  volume  of  386  pages,  illustrated.     Cloth,  $3.00  net. 
This  monograph  is  the  only  one  in  any  language  covering  the  entire  subject 
of  the  Surgical  Complications  and   Sequels  of  Typhoid  Fever.     The  work  will 
prove  to  be  of  importance  and  interest  not  only  to  the  general  surgeon  and  phy- 
sician, but  also  to  many  specialists — laryngologists,  ophthalmologists,  gynecolo- 
gists, pathologists,  and  bacteriologists — as  the  subject  has  an  important  bearing 
upon  each  one  of  their  spheres.     The  author's  conclusions  are  based  on  reports 
of  over  1700  cases,  including  practically  all  those  recorded  in  the  last  fifty  years. 
Reports  of  cases  have  been  lirought  down  to  date,  many  having  been  added 
while  the  work  was  in  press. 

"  This  is  probably  the  first  and  only  work  in  the  English  language  that  gives  the  reader  a 
clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human  organ- 
ism. This  book  should  be  in  the  possession  of  every  medical  man  in  America." — American 
Medico-Surgical  Bulletin. 


CATALOGUE.  OF  MEDICAL    WORKS.  23 

MODERN  SURGERY,  GENERAL  AND  OPERATIVE.  By  John 
Chalmers  DaCosta,  M.  D.,  Professor  of  Practice  of  Surgery  and  Clin- 
ical Surgeiy,  Jefferson  Medical  College,  Philadelphia;  Surgeon  to  the  Phil- 
adelphia Hospital,  etc.  Handsome  octavo  volume  of  911  pages,  profusely 
illustrated.     Cloth,  ^4.00  net;  Half-Morocco,  ^5.00  net. 

Second  Edition,  Rewritten  and  Greatly  Enlarged. 

The  remarkable  success  attending  DaCosta's  Manual  of  Surgery,  and  the 
general  favor  with  which  it  has  been  received,  have  led  the  author  in  this 
revision  to  produce  a  complete  treatise  on  modern  surgery  along  the  same  lines 
that  made  the  former  edition  so  successful.  The  book  has  been  entirely  re- 
written and  very  much  enlarged.  The  old  edition  has  long  been  a  favorite  not 
only  with  students  and  teachers,  but  also  with  practising  physicians  and  sur- 
geons, and  it  is  believed  that  the  present  work  will  find  an  even  wider  field  of 
usefuhiess. 

"  We  know  of  no  small  work  on  surgery  in  the  English  hingiiage  which  so  well  fulfils  the 
requirements  of  the  modern  student." — Medico-Chirnrgiail  Journal ,  Bristol,  England. 

"  The  author  has  presented  concisely  and  accurately  the  principles  of  modern  surgery. 
The  book  is  a  valuable  one  which  can  be  recommended  to  students  and  is  of  great  value  to 
the  general  practitioner." — American  Journal  of  the  Medical  Sciences. 

A  MANUAL  OF  ORTHOPEDIC  SURGERY.  By  James  E.  Moore, 
M.D.,  Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume 
of  356  pages,  with  177  beautiful  illustrations  from  photographs  made  spec- 
ially for  this  work.     Cloth,  ^2.50  net. 

A  practical  book  based  upon  the  author's  experience,  in  which  special  stress 
is  laid  upon  early  diagnosis  and  treatment  such  as  can  be  carried  out  by  the 
general  practitioner.  The  teachings  of  the  author  are  in  accordance  with  his 
belief  that  true  conservatism  is  to  be  found  in  the  middle  course  between  the 
surgeon  who  operates  too  frequently  and  the  orthopedist  who  seldom  operates. 

"A  very  demonstrative  work,  every  illustration  of  which  conveys  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
SI.  Louis  Medical  and  Surgical  yournal. 

ELEMENTARY   BANDAGING    AND    SURGICAL    DRESSING, 

With  Directions  concerning  the  Immediate  Treatment  of  Cases  of  Emer- 
gency. For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S., 
late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  80 
illustrations.     Cloth,  flexible  covers,  75  cents  net. 

This  little  book  is  chiefly  a  condens.ition  of  those  portions  of  Pye's  "  .Surgical 
Handicraft"  which  ileal  with  bandaging,  sjilinting,  etc.,  and  of  those  which 
treat  of  the  management  in  the  first  instance  of  cases  of  emergency.  The 
directions  given  are  thoroughly  practical,  and  the  book  will  prove  extremely  use- 
ful to  students,  surgical  nurses,  and  dressers. 

"  The  author  writes  well,  the  di.igrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  yournal. 


24  iV.   B.   SAUNDERS' 


A    TEXT-BOOK    OF    MATERIA    MEDICA,    THERAPEUTICS 
AND  PHARMACOLOGY.     By  George  F.  Butler,  Ph.G.,  M.D., 
Professor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  College  of 
Physicians   and    Surgeons,   Chicago;    Professor  of   Materia    Medica   and 
Therapeutics,    Northwestern    University,  Woman's    Medical    School,   etc 
Octavo,  874  pages,  illustrated.     Cloth,  ^4.00  net ;  Sheep,  ^5.00  net. 
Third  Edition,  Thoroughly  Revised. 
A  clear,  concise,  and  practical  text-book,  adapted  for  permanent  reference  no 
less  than  for  the  requirements  of  the  class-room. 

The  recent  important  additions  made  to  our  knowledge  of  the  physiological 
action  of  drugs  are  fully  discussed  in  the  present  edition.  The  book  has  been 
thoroughly  revised  and  many  additions  have  been  made. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory  of  any 
single-volume  works  on  materia  medica  in  the  market." — Journal  0/  the  American  Medical 
Associatiuti. 

TUBERCULOSIS  OF  THE  GENITO-URINARY  ORGANS, 
MALE  AND  FEMALE.  By  Nichola.s  Senn,  M.D.,  Ph.D.,  LL.D., 
Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 
College,  Chicago.  Handsome  octavo  volume  of  320  pages,  illustrated^ 
Cloth,  $3.00  net. 

Tuberculosis  of  the  male  and  female  genito-urinary  organs  is  such  a  frequent, 
distressing,  and  fatal  affection  that  a  special  treatise  on  the  subject  appears  to 
fill  a  gap  in  medical  literature.  In  the  present  work  the  bacteriology  of  the  sub- 
ject has  received  due  attention,  the  modern  resources  employed  in  the  differen- 
tial diagnosis  between  tubercular  and  other  inflammatory  affections  are  fully 
described,  and   the  medical   and  surgical  therapeutics  are  discussed   in  detail. 

"An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

A  TEXT-BOOK  OF  DISEASES  OF  WOMEN.  By  Charles  B. 
Penrose,  M.D.,  Ph.D.,  Professor  of  Gynecology  in  the  University  of 
Pennsylvania;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Octavo 
volume  of  531  pages,  with  317  illustrations,  nearly  all  from  drawings  made 
for  this  work.     Cloth,  ^3.75  net. 

Third  Edition,  Revised. 

In  this  work,  which  has  been  written  for  both  the  student  of  gynecology  and 
the  general  practitioner,  the  author  presents  the  best  teaching  of  modern  gyne- 
cology untrammelled  by  antiquated  theories  or  methods  of  treatment.  In  most 
instances  but  one  plan  of  treatment  is  recommended,  to  avoid  confusing  the 
student  or  the  physician  wlio  consults  the  book  for  practical  guidance. 

"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women'  received.  1  have 
already  recommended  it  to  my  class  as  THE  BEST  book." — Howard  A.  Kelly,  Professor 
0/  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Aid. 

"  The  book  is  to  be  commended  without  reserve,  not  only  to  the  student  but  to  the  general 
practitioner  who  wishes  to  have  the  latest  and  best  modes  of  treatment  explained  with  absolute 
clearness." —  Therapeutic  Gazette. 


CATALOGUE    OF  MEDICAL    WORKS.  25 

SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  John 
Collins  Warren,  M.  D.,  LL.D.,  Professor  of  Surgery,  Medical  Depart- 
ment Harvard  University.  Handsome  octavo,  832  pages,  with  136  relief 
and  lithograpliic  illustrations,  33  of  which  are  printed  in  colors. 

Second  Edition, 

with  an  Appendix  devoted  to  the  Scientific  Aids  to  Surgical  Diagnosis,  and 
a  series  of  articles  on  Regional  Bacteriology.  Cloth,  ^5.00  net;  Half- 
Morocco,  $6.00  net. 

Without   Exception,  the  Illustrations    are   the  Best  ever  Seen   in    a 
"Work  of  this  Kind. 

"A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without  ex- 
ception, from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  *  *  *  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their 
coloring  and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the 
barrel  of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery,  Philadelphia. 

"  It  is  the  handsomest  specimen  of  book-making  *  *  *  that  has  ever  been  issued  from  the 
American  medical  press." — American  Journal  of  the  Medical  Sciences,  Philadelphia. 

PATHOLOGY  AND   SURGICAL  TREATMENT   OF  TUMORS. 

By  N.  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College ;  Professor  of  Surgery,  Chicago 
Polyclinic ;  Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief, 
St.  Joseph's  Hospital,  Chicago.  One  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  New  and  enlarged  Edition 
in  Preparation. 

Books  specially  devoted  to  this  subject  are  few,  and  in  our  text-books  and 
systems  of  surgeiy  this  part  of  surgical  pathologj'  is  usually  condensed  to  a  de- 
gree incompatible  with  its  scientific  and  clinical  importance.  The  author  spent 
many  years  in  collecting  the  material  for  this  work,  and  has  taken  great  pains 
to  present  it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the  student, 
a  work  of  reference  for  the  practitioner,  and  a  reliable  guide  for  the  surgeon. 

"The  most  exhaustive  of  any  recent  book  in  Engli.sh  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  ....  and  the  author  has 
given  a  notable  and  lasting  contribution  to  surgery." — Journal  of  the  American  Medical 
Association ,  Chicago. 

LECTURES    ON    RENAL    AND    URINARY     DISEASES.      By 

RoiiERT  Saundky,  M.  D.,  Edin.,  Fellow  of  the  Royal  College  of  Physicians, 
London,  and  of  the  Royal  Medico-Chirurgical  Society;  Physician  to  the 
General  Hospital.  Octavo  volume  of  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  $2.50  net. 

"  The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical  yournal. 


26  W.   B.   SAUNDERS' 


A  HANDBOOK  FOR  NURSES.  By  J.  K.  Watson,  M.  D.,  Edin., 
Assistant  House-Surgeon,  Sheffield  Royal  Hospital.  American  Edition, 
under  the  supervision  of  A.  A.  Stevens,  A.  M.,  M.  D.,  Professor  of 
Pathology,  Woman's  Medical  College,  Philadelphia.  l2mo,  413  pages, 
73  illustrations.     Cloth,  $1.50  net. 

This  work  aims  to  supply  in  one  volume  that  information  which  so  many 
nurses  at  the  present  time  are  trying  to  extract  from  various  medical  works,  and 
to  present  that  information  in  a  suitable  form.  Nurses  must  necessarily  acquire 
a  certain  amount  of  medical  knowledge,  and  the  author  of  this  book  has  aimed 
judiciously  to  cater  to  this  need  with  the  object  of  directing  the  nurses'  pursuit 
of  medical  information  in  proper  and  legitimate  channels.  The  book  represents 
an  entirely  new  departure  in  nursing  literature,  insomuch  as  it  contains  useful 
information  on  medical  and  surgical  matters  hitherto  only  to  be  obtained  from 
expensive  works  written  expressly  for  medical  mer. 

A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Keating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Editor  "Cyclopaedia  of  the  Diseases  of  Children,"  etc.;  and 
Henry  Hamilton,  with  the  Collaboration  of  J.  Chalmers  DaCosta, 
M.  D.,  and  Frederick  A.  Packard,  M.  D.  One  very  attractive  volume 
of  over  800  pages.  Second  Revised  Edition.  Prices:  Cloth,  ;^5. 00  net; 
Sheep  or  Half-Morocco,  ^6.00  net;  with  Denison's  Patent  Ready-Refer- 
ence Index;  without  patent  index.  Cloth,  $4.00  net;  Sheep  or  Half- 
Morocco,  ^5.00  net. 

PROFESSIONAL  OPISTIONS. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommending 
ft  to  my  classes." 

Hbnky  M.  Lyman,  M.  D., 
Professor  of  Principles  and  Practice  of  Medicine,  Rush  Medical  College,  Chicago,  III. 

'I  am  convinced  that  it  will  De  a  very  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.  A.  LiNDSLEY,  M.  D., 
trofessor  of  Theory  and  Practice  0/  Medicine,  Medical  Dept.  Yale  UniTersity : 

iiecretary  Connecticut  State  Board  0/  Health,  New  Haven.  Conn. 


AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 
fes.sor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.  Edited  by  his  sons, 
Samuel  W.  Gross,  M.  D.,  LL.D.,  and  A.  Haller  Gross,  A.  M.,  of  the 
Philadelphia  Bar.  Preceded  by  a  Memoir  of  Dr.  Gross,  by  the  late 
Austin  Flint,  M.  D.,  LL.D.  In  two  handsome  volumes,  each  containing 
over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine  Fronti.spiece 
engraved  on  steel.     Price  per  Volume,  ^2.50  net. 


CATALOGUE    OF  MEDICAL    WORKS.  2/ 

PRACTICAL  POINTS  IN  NURSING.  For  Nurses  in  Private 
Practice.  By  Emily  A.  M.  Stoney,  Graduate  of  the  Training-School 
lor  Nurses,  Lawrence,  Mass. ;  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  handsomely 
illustrated  with  73  engravings  in  the  text,  and  9  colored  and  half-tone 
Dlates.     Cloth.     Price,  ti.i^  ne«. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  the  author  explains,  in  popular  language  and  in  the  shortest 
possible  form,  the  entire  range  oi  pi-ivate  nursing  as  distinguished  from  hospital 
nursing,  and  the  nurse  is  instructed  how  best  to  meet  the  various  emergencies  of 
medical  and  surgical  cases  when  distant  from  medical  or  surgical  aid  or  when 
thrown  on  her  own  resources. 

nn  especially  valuable  feature  of  the  work  will  be  found  in  the  directions  to 
the  nurse  how  to  improvise  everything  ordinarily  needed  in  the  sick-room,  where 
the  embarrassment  of  the  nurse,  owing  to  the  want  of  proper  appliances,  is  fre- 
quently extreme. 

The  work  has  been  logically  divided  into  the  followins  sections : 

I.  The  Nurse  :  her  responsibilities,  qualihcations,  equipment,  etc. 
II.  The  Sick-Room  :  its  selection,  preparation,  and  management. 
'II.  The  Patient :  duties  of  the  nurse  in  medical,  surgical,  obstetric,  and  gyne- 
cologic cases. 
IV.  Nursing  in  Accidents  and  Emergencies. 
V.  Nursing  in  Special  Medical  Cases. 
VI.  Nursing  of  the  New-born  and  Sick  Chiiaren. 
VII.  Physiology  and  Descriptive  Anatomy. 

The  Appendix  contpins  much  information  in  compact  form  that  will  be  found 
of  great  value  to  the  nurse,  including  Rules  for  Feeding  the  Sick ;  Recipes  for 
Invalid  Foods  and  Beverages ;  Tables  of  Weights  and  Measures ;  Table  for 
Computing  the  Date  of  Labor;  List  of  Abbreviations ;  Dose-List;  and  a  full 
and  complete  Glossary  of  Medical  Terms  and  Nursing  Treatment. 

"This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — American  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children,  Aug.,  i8q6. 

A  TEXT-BOOK  OF  BACTERIOLOGY,  including  the  Etiology  and 
Prevention  of  Infective  Diseases  and  an  account  of  Yeasts  and  Moulds, 
Haematozoa,  and  Psorosperms.  By  Edgar  M.  Crckikshank,  M.  B.,  Pro- 
tessor  of  Comparative  Pathology  and  Bacteriology,  King's  College,  London. 
A  handsome  octavo  volume  of  700  pages,  with  273  engravings  in  the  text, 
and  22  original  and  colored  plates.     Price.  S6.50  net. 

This  book,  though  nominally  a  Fouith  Edition  9f  Professor  Crookshank's 
"Manual  of  Bacteriology,"  is  practically  a  new  work,  the  old  one  having 
t)een  reconstructed,  greatly  enlarged,  revised  throughout,  and  largely  rewritten, 
lorming  a  text-book  for  the  Bacteriological  Laboratory,  for  Medical  Ofticers  of 
Health,  and  for  Veterinary  Insoectors. 


28  PV.  B.    SAUNDERS' 


MEDICAL  DIAGNOSIS.  By  Dr.  Oswald  Vierordt,  Professor  of 
Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Fifth  Enlarged  German  Edition,  with  the  author's  permission,  by 
Francis  H.  Stuart,  A.  M.,  M.  D.  In  one  handsome  royal-octavo  volume 
of  600  pages.  194  fine  wood-cuts  m  the  text,  many  of  them  in  colors. 
Prices:  Cloth,  ^4.00  net;  Sheep  or  Half- Morocco,  ^5.00  net. 

FOURTH  AMERICAN  EDITION,  FROM  THE  FIFTH  REVISED  AND 
ENLARGED  GERMAN  EDITION. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as  a 
factor  in  the  origin  of  disease. 

The  present  edition  of  this  highly  successful  work  has  been  translated  from 
the  fifth  German  edition.  Many  alterations  have  been  made  throughout  the 
book,  but  especially  in  the  sections  on  Gastric  Digestion  and  the  Nervous  System. 

It  will  be  found  that  all  the  qualities  which  served  to  make  the  earlier  editions 
so  acceptable  have  been  developed  with  the  evolution  of  the  work  to  its  present 
form. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPHI- 
LITIC AFFECTIONS.  (American  Edition.)  Translation  from 
the  French.  Edited  by  J.  J.  Pringle,  M.  B.,  F.  R.  C.  P.,  Assistant  Phy- 
sician to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the 
Middlesex  Hospital,  London.  Photo-lithochromes  from  the  famous  models 
of  dermatological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis 
Hospital,  Paris,  with  explanatory  wood-cuts  and  letter-press.  In  12  Parts, 
at  ^3.00  per  Part. 

"  Of  all  the  atlases  of  skin  diseases  which  have  been  published  in  recent  years,  the  present 
one  promises  to  be  of  greatest  interest  and  value,  especially  from  the  standpoint  of  the 
general  practitioner." — American  Medico-Surgical  Bulletin,  Feb.  22,  1896. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal,  Feb.  15,  1896. 

"  An  interesting  feature  of  the  Atlas  is  the  descriptive  text,  which  is  written  for  each  picture 
by  the  physician  who  treated  the  case  or  at  whose  instigation  the  models  have  been  made. 
We  predict  for  this  truly  beautiful  work  a  large  circulation  in  all  parts  of  the  medical  world 
where  the  names  St.  Louis  and  Baretta  have  preceded  iX.."— Medical  Record,  N.  Y.,  Feb.  i, 
1896. 

A  TEXT-BOOK  OF  MECHANO-THERAPY  (MASSAGE  AND 
MEDICAL  GYMNASTICS).  By  Axel  V.  Grafstrom,  B.  Sc, 
M.  D.,  late  Lieutenant  in  the  Royal  Swedish  Army;  late  House  Physi- 
cian, City  Hospital,  Blackwell's  Island,  New  York.  i2mo,  139  pages, 
illustrated.     Cloth,  Jgi. 00  net. 


CATALOGUE    OF  MEDICAL    WORKS.  2g 

DISEASES  OF  THE  EYE.  A  Hand-Book  of  Ophthalmic  Prac- 
tice. By  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology  in 
the  Jefferson  Medical  College,  Philadelphia,  etc.  A  handsome  royal- 
octavo  volume  of  696  pages,  with  255  fine  illustrations,  many  of  which  are 
original,  and  2  chromo-lithographic  plates.  Prices :  Cloth,  i^4.oo  net ; 
Sheep  or  Half-Morocco,  ^5.00  net. 

THIRD  EDITION,  THOROUGHLY  REVISED. 

In  the  third  edition  of  this  text-book,  destined,  it  is  hoped,  to  meet  the  favor- 
able reception  which  has  been  accorded  to  its  predecessors,  the  work  has  been 
revised  thoroughly,  and  much  new  matter  has  been  introduced.  Particular 
attention  has  been  given  to  the  important  relations  wiiich  micro-organisms  bear 
to  many  ocular  diseases.  A  number  of  special  paragraphs  on  new  subjects  have 
been  introduced,  and  certain  articles,  including  a  portion  of  the  chapter  on 
Operations,  have  been  largely  rewritten,  or  at  least  materially  changed.  A 
number  of  new  illustrations  have  been  added.  The  Appendix  contains  a  full 
description  of  the  method  of  determining  the  corneal  astigmatism  with  the 
ophthalmometer  of  Javal  and  Schiotz,  and  the  rotation  of  the  eyes  with  the 
tropometer  of  Stevens. 

"A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.     I  am  satisfied  that  unusual  success  awaits  it." 

William  Pepper,  M.  D. 
Provost  and  Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Medicine 
in  the  University  of  Pennsylvania. 

"A  clearly  written,  comprehensive  manual.  .  .  .  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering  upon 
the  study  of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  It  is  hardly  too  much  to  say  that  for  the  student  and  practitioner  beginning  the  study  of 
Ophthalmology,  it  is  the  best  single  volume  at  present  published." — Medical  2\'ews. 

"  It  is  a  very  useful, satisfactory,  and  safe  guide  for  the  student  and  the  practitioner,  and 
one  of  the  best  works  of  this  scope  in  the  English  language." — Annals  of  Ophthaltnolo^y . 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital,  London ; 
and  Arthur  E.  Giles,  M.  D.,  B.  Sc,  Lond.,  F.  R.C.  S.,  Edin.,  Assistant 
Surgeon  to  Chelsea  Hospital,  London.  436  pages,  handsomely  illustrated. 
Cloth,  $2.50  net. 

The  authors  have  placed  in  the  hands  of  the  physician  and  student  a  concise 
yet  comprehensive  guide  to  the  study  of  gynecology  in  its  most  modern  develop- 
ment. It  has  been  their  aim  to  relate  facts  and  describe  methods  belonging  to 
the  science  and  art  of  gynecology  in  a  way  that  will  prove  useful  to  students  for 
examination  purposes,  and  which  will  also  enable  the  general  physician  to  prac- 
tice this  important  department  of  surgery  with  advantage  to  his  patients  and  with 
satisfaction  to  himself. 

"  The  book  is  very  well  prepared,  and  is  certain  to  be  well  received  by  the  medical  public." 
— British  Medical  Journal. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  A?iy ." ^Journal  of  the 
American  Medical  Association. 


30  m:  JB.  SAUNDEkS^ 


TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA.  Spe- 
cially written  for  Students  of  Medicine.  By  Joseph  McFarland, 
M.  D.,  Frofessor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical 
College  of  Philadelphia,  etc.  497  pages,  finely  illustrated.  Price,  Cloth, 
^2.50  net. 

SECOND  EDITION,  REVISED  AND  GREATLY  ENLARGED. 
The  woik  is  intended  to  be  a  text-book  for  the  medical  student  and  for  the 
practitioner  who  has  had  no  recent  laboratory  training  ni  this  department  of  medi- 
cal science.  The  instructions  given  as  to  needed  apparatus,  cultures,  stainings, 
microscopic  examinations,  etc.  are  ample  for  the  student's  needs,  and  will  afford 
to  the  physician  much  information  that  will  interest  and  profit  him  relative  to  a 
subject  which  modern  science  shows  to  go  far  in  explaining  the  etiology  ol  many 
diseased  conditions. 

In  this  second  edition  the  work  has  been  brought  up  to  date  in  all  depart- 
ments of  the  subject,  and  numerous  additions  have  been  made  to  the  technique 
m  the  endeavor  to  make  the  book  fulfil  the  double  purpose  of  a  systematic  work 
upon  bacteria  and  a  laboratory  guide. 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable,  and  the  book  should  prove 
useful  to  those  for  whom  it  is  written. — London  Lancet,  Aug.  29,  1896. 

"  The  author  has  sncceded  admirably  in  presenting  the  essential  details  of  bacteriological 
technics,  together  with  a  judiciously  chosen  summary  of  our  present  knowledge  of  pathogenic 
bacteria.  .  .  .  The  work,  we  think,  should  have  a  wide  circulation  among  English-speaking 
students  of  medicine." — N.  Y.  Medical  Journal,  April  4,  1896. 

"  The  book  will  be  found  of  considerable  use  by  medical  men  who  have  not  had  a  special 
bacteriological  training,  and  who  desire  to  understand  this  important  branch  of  medical 
science." — Edinburgh  Medical  Journal,  July,  i8y&. 

LABORATORY    GUIDE    FOR    THE    BACTERIOLOGIST.      By 

Langdon  Frothingham,  M.  D.  V.,  Assistant  in  Bacteriology  and  Veteri- 
nary Science,  Sheffield  Scientific  School,  Yale  University.  Illustrated, 
Price,  Clotn,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  ana 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.     The  book  is  especially  intended  for  use  in  laboratory  work 

"  It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  necessary 
for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking  up  trie 
various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — American  Mea.- 
^urg.  Bulletin. 

FEEDING  IN  EARLY  INFANCY.  By  Arthur  V.  Meigs,  M.  D. 
Bound  in  limp  cloth,  flush  edges.     Price,  25  cents  net. 

Synopsis  :  Analyses  of  Milk — Importance  of  the  Subject  of  Feeding  in  Early 
Infancy — Proportion  of  Casein  and  Sugar  in  Human  Milk — Time  to  Begin  Arti- 
ficial Feeding  of  Infants — Amount  of  Food  to  be  Administered  at  Each  Feed- 
ing— Intervals  between  Feedings — Increase  in  Amount  of  Food  at  Different 
Periods  of  Infant  Development — Unsuitableness  of  Condensed  Milk  as  a  Sub- 
stitute for  Mother's  Milk — Objections  to  Sterilization  or  "  Pasteurization  *'  ot 
Milk — Advances  made  in  the  Method  of  Artificial  Feeding  of  Infants. 


CATALOGUE    OF  MEDICAL    WORKS.  3 1 

MATERIA  MEDICA  FOR  NURSES.  By  Emily  A.  M.  Stoney, 
Graduate  of  the  Training-school  for  Nurses,  Lawrence,  Mass.  ;  late 
Superintendent  of  the  Training-school  for  Nurses,  Carney  Hospital,  South 
Boston,  Mass.     Handsome  octavo,  300  pages.     Cloth,  1^1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of 
which  are  introduced  to  render  it  more  practical  and  generally  useful.  The 
general  plan  of  contents  follows  the  lines  laid  down  in  training-schools  for 
nurses,  but  the  book  contains  much  useful  matter  not  usually  included  in  works 
of  this  character,  such  as  Poison-emergencies,  Ready  Dose-list,  Weights  and 
Measures,  etc.,  as  well  as  a  Glossary,  defining  all  tlie  terms  in  Materia  Medica, 
and  describing  all  the  latest  drugs  and  remedies,  which  have  been  generally 
neglected  by  other  books  of  the  kind. 

ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI» 
CAL  DISSECTION,  containing  "  Hints  on  Dissection  "  By  Charles 
B.  Nancrede.  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy ;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  Post  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  ^2.00  net. 

Neither  pains  nor  expense  has  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  and 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anatomy, 

A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Instructor  in  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Professor  of  Pathology  in  the  Woman's  Medical  College  of 
Pennsylvania.  Specially  intended  for  students  preparing  ftir  graduation 
and  hospital  examinations.  Post  8vo,  519  pages.  Numerous  illustrations 
and  selected  formula;.     Price,  bound  in  flexible  leather,  ^2.00  net. 

FIFTH  EDITION,  REVISED  AND  ENLARGED. 

Contributions  to  the  science  ol  medicine  have  poured  in  so  rapidly  during  the 
last  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  extended  experience  in 
teaching,  the  author  has  been  enableti,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bnng  withir.  r.  """finarative'.v  small  compass  a  comolete  outline  of  the  prac- 
tice ol  medicine. 


32  IV.   B.   SAUNDERS' 


MANUAL    OF    MATERIA    MEDICA    AND    THERAPEUTICS. 

By  A.  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Professor  of  Pathology  in  the  Woman's 
Medical  College  of  Pennsylvania.  445  pages.  Price,  bound  in  flexible 
leather,  52.25. 

SECOND   EDITION,    REVISED. 

This  wholly  new  volume,  which  is  based  on  the  last  edition  of  the  Pharma- 
copoeia, comprehends  the  following  sections  :  Physiological  Action  of  Drugs ; 
Drugs ;  Remedial  Measures  other  than  Drugs ;  Applied  Therapeutics  ;  Incom- 
patibility in  Prescriptions;  Table  of  Doses;  Index  of  Drugs;  and  Index  of 
Diseases;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

"  The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
;iccurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare." —  Therapeutic  Gazette. 

"  Far  superior  to  most  of  its  class  ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate." — New  York  Medical  Journal. 

"  The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work,  .  .  . 
and  it  will  be  found  a  reliable  guide." — University  Medical  Magazine. 

NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Ap- 
plications and  Modes  of  Administration.  By  David  Cerna,  M.  D., 
Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.     Post-octavo,  253  pages.     Price,  $1.25. 

SECOND  EDITION,  RE-WRITTEN  AND  GREATLY   ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"  Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Review. 


TEMPERATURE  CHART.     Prepared  by  D.  t.  Laine,  M.  D.      Size 
8x  13^  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal   Excretions,  Food,  Remarks,  etc.     On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  (^ 
Typhoid  Fever.  I 


CATALOGUE    OF  MEDICAL    WORKS.  33 

A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
TICAL. For  the  Use  of  Students.  By  Arthur  Clarkson,  M.  B., 
C.  M.,  Edin.,  formerly  Demonstrator  of  Physiology  in  the  Owen's  College, 
Manchester;  late  Demonstrator  of  Physiology  in  the  Yorkshire  College, 
Leeds.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and  174 
beautifully  colored  original  illustrations.  Price,  strongly  bound  in  Cloth, 
^4.00  net. 

The  purpose  of  the  writer  in  this  work  has  been  to  furnish  the  student  of  His- 
tology, in  one  volume,  wilh  both  the  descriptive  and  the  practical  part  of  the 
science.  The  first  two  chapters  are  devoted  to  the  consideration  of  the  general 
methods  of  Histology ;  subsequently,  in  each  chapter,  the  structure  of  the  tissue 
or  organ  is  first  systematically  described,  the  student  is  then  taken  tutorially  over 
the  specimens  illustrating  it,  and,  finally,  an  appendix  affords  a  short  note  of  the 
methods  of  preparation. 

"  The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text-books,  and 
is  to  be  highly  recommended." — Ne7v  York  Medical  Journal. 

"  One  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the  book  will 
attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

THE  PATHOLOGY  AND  TREATMENT  OF  SEXUAL  IM- 
POTENCE. By  Victor  G.  Vecki,  M.  D.  From  the  second  Ger- 
man edition,  revised  'and  rewritten.  Demi-octavo,  about  300  pages. 
Cloth,  $2.00  net. 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  country  in  the 
truly  scientific  spirit  that  it  deserves,  and  this  volume  will  come  to  many  as  a 
revelation  of  the  possibilities  of  therapeusis  in  this  important  field.  Dr.  Vecki's 
work  has  long  been  favoralily  known,  and  the  German  book  has  received  the 
highest  consideration.  This  edition  is  more  than  a  mere  translation,  for,  although 
based  on  the  German  edition,  it  has  been  entirely  rewritten  by  the  author  in 
English. 

"  The  work  can  be  recommended  as  a  scholarly  treatise  on  its  subject,  and  it  can  be  read 
with  advantage  by  many  practitioners."— /oz^rwa/  of  the  American  Medical  Association. 

THE  TREATMENT  OF  PELVIC  INFLAMMATIONS 
THROUGH  THE  VAGINA.  By  W.  R.  Pryor,  M.  D.,  Pro- 
fessor of  Gynecology  in  the  New  York  Polyclinic.  l2mo,  248  pages, 
handsomely  illustrated.     Cloth,  $2.00  net. 

In  this  book  the  author  directs  the  attention  of  the  general  practitioner  to  a 
surgical  treatment  of  the  pelvic  diseases  of  women.  There  exists  the  utmost 
confusion  in  the  profession  regarding  the  most  successful  methods  of  treating 
pelvic  inflammations;  and  inasmuch  as  inflammatory  lesions  constitute  the  ma- 
jority of  all  pelvic  diseases,  the  subject  is  an  important  one.  It  has  been  the 
endeavor  of  the  author  to  put  down  every  little  detail,  no  matter  how  insig- 
nificant, which  might  be  of  service. 


34  ^.   B.    SAUNDERS' 


DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.M.,  M.  D., 
Professor  of  Gynecology  in  the  New  York  School  of  Clinical  Medicine; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New  ' 
York  City.  In  one  handsome  octavo  volume  of  728  pages,  illustrated  by 
335  engravings  and  colored  plates.  Prices:  Cloth,  ^4.00  net;  Sheep  or 
Half-'Morocco,  ^5.00  net. 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  embryology  and  the  anatomy 
of  \.\\t  female  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions,  instruments,  apparatus,  and  operations. 

Second  Edition,  Thorougfilij  Revised. 

The  first  edition  of  this  work  met  with  a  most  appreciative  reception  by  the 
medical  press  and  profession  both  in  this  country  and  abroad,  and  was  adopted 
as  a  text-book  or  recommended  as  a  book  of  reference  by  nearly  one  htmdred 
colleges  in  the  United  States  and  Canada.  The  author  has  availed  himself  of 
the  opportunity  afforded  by  this  revision  to  embody  the  latest  approved  advances 
in  the  treatment  employed  in  this  important  branch  of  Medicine.  He  has  also 
more  extensively  expressed  his  own  opinion  on  the  comparative  value  of  the 
different  methods  of  treatment  employed. 

"One  of  the  best  text-bonks  for  students  and  practitioners  which  has  been  published  in 
the  English  language;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  aiuhor  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  book  invaluable  counsel  and  help." 

Thad.  a.  Rbamy,  M.  D.,  LL.D., 
Professor  0/  Clinical  Gynecology,  Medical  College  of  Ohio  ;   Gynecologist  to  the  Good 
Samaritan  and  Cincinnati  Hospitals. 


A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     Price,  Cloth  (interleaved),  iJSi.oo  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
roora,  as  the  subject  is  presented  in  a  manner  at  once  systematic,  clear,  succinct, 
-pnd  practical. 


CATALOGUE    OF  MEDICAL    WORKS.  35 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited 
by  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital 
of  the  University  of  Pennsylvania ;  Fellow  of  the  American  Academy  of 
Medicine.  Containing  the  pronunciation  and  definition  of  all  the  principal 
vifords  used  in  medicine  and  the  kindred  sciences,  with  64  extensive  tables. 
Handsomely  bound  in  flexible  leather,  limp,  with  gold  edges  and  patent 
thumb  index.     Price,  $1.00  net ;  with  thumb  index,  ^1.25  net. 

SECOND  EDITION,  REVISED. 

This  is  the  ideal  pocket  lexicon.  It  is  an  absolutely  new  book,  and  not  a  re- 
vision of  any  old  work.  It  is  complete,  defining  all  the  terms  of  modern  medi- 
cine and  forming  an  unusually  complete  vocabulary.  It  gives  the  pronunciation 
of  all  the  terms.  It  makes  a  special  feature  of  the  newer  words  neglected  by 
other  dictionaries.  It  contains  a  wealth  of  anatomical  tables  of  special  value  to 
students.     It  forms  a  handy  volume,  indispensable  to  every  medical  man. 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1800  Formulse,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions ;  with  an  Appendix  containing  Posological  Table,  Formulse 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Female  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery, 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  morocco,  with  side  index,  wallet,  and  flap.  Price,  §1.75 
net. 

FIFTH  EDITION,  THOROUGHLY  REVISED. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given, is  unusually  reliable." — New  York  Medical  Record. 

A  COMPENDIUM  OF  INSANITY.  By  John  B.  Chapin,  M.D.,  LL.D., 
I'hysician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  late  Physician- 
Superintendent  of  the  Willaid  State  Hospital,  New  York  ;  Honorary  Mem- 
ber of  the  Medico-Psychological  Society  of  Great  Britain,  of  the  Society  of 
Mental  Medicine  of  Belgium.  lamo,  234  pages,  illust.  Cloth,  $1.25  net. 
The  author  has  given,  in  a  condensed  and  concise  form,  a  compendium  of 

Diseases  of  the  Mind,  for  the  convenient  use  and  aid  of  physicians  and  students. 

It  contains  a  clear,  concise  statement  of  the   clinical  aspects  of  the   various   ab- 

normal  mental  conditions,  with  directions  as  to  the  most  approved  methods  of 

managing  and  treating  the  insane 


"  The  pr.-ictical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  A 
desire  especially,  however,  to  call  attention  to  the  fact  that  in  the  subject  of  the  thcrapeut 
of  insanity  the  work  is  exceedingly  valuable.  The  author  has  made  a  distinct  addition  to  t 
literature  of  his  %^i.c\v\\.y ." —Philadelphia  Medical  Journal. 


\\'e 
tics 
the 


36  W.   B.    SAUNDERS' 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

SECOND  EDITION,  REVISED  FORM. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

On  the  back  of  each  blank  is  a  list  of  instruments  used — viz.  general  instru 
ments,  etc.,  required  for  all  operations ;  and  special  instruments  for  surgery  of 
the  brain  and  spine,  mouth  and  throat,  abdomen,  rectum,  male  and  female 
genito-urinary  organs,  the  bones,  etc. 

The  whole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur- 
geon's office  or  in  the  hospital  operating-room. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  " — New  York  Medical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 

"  The  plan  is  a  capital  one."— Boston  Medical  and  Surgical  Journal . 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  536  pages,  87  full-page  plates.  Price, 
Cloth,  ^2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 

"  There  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country,  and 
we  predict  for  it  a  wide  circulation." — American  yournal  of  Pharmacy. 

DIET  IN  SICKNESS  AND  IN  HEALTH.  By  Mrs.  Ernest  Hart, 
formerly  Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London 
School  of  Medicine  for  Women ;  with  an  Introduction  by  Sir  Henry 
Thompson,  F.  R.  C.  S.,  M.  D.,  London.  220  pages ;  illustrated.  Price, 
Cloth,  $1.50. 

Useful  to  those  who  have  to  nurse,  feed,  and  prescribe  for  the  sick.  In 
each  case  the  accepted  causation  of  the  disease  and  the  reasons  for  the  special 
diet  prescribed  are  briefly  described.  Medical  men  will  find  the  dietaries  and 
recipes  practically  useful,  and  likely  to  save  them  trouble  in  directing  the  dietetic 
treatment  of  patients. 


CATALOGUE    OF  MEDICAL    WORKS.  37 

A  MANUAL   OF    PHYSIOLOGY,  with   Practical    Exercises.     For 

Students  and  Practitioners.    By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc, 

lately  Examiner  in   Physiology,  University  of  Aberdeen,  and  of  the  New 

Museums,  Cambridge  University ;  Professor  of  Physiology  in  the  Western 

Reserve  University,  Cleveland,  Ohio.     Handsome  octavo  volume  of  848 

pages,  with  300  illustrations  in  the  text,  and  5  colored  plates.    Price,  Cloth, 

^3.75  net. 

THIRD  EDITION,  REVISED. 

"It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one  oj 
the  very  best  English  text-books  on  the  subject." — London  Lancet. 

"  Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so  nearly 
comes  up  to  the  ideal  as  does  Professor  Stewart's  volume." — British  Medical  Journal. 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OF  THE  THORAX. 

By  Arthur  M.  Corwin,  A.  M.,  M.  D.,  Demonstrator  of  Physical  Diagno- 
sis in  the  Rush  Medical  College,  Chicago;  Attending  Physician  to  the 
Central  Free  Dispensary,  Department  of  Rhinology,  Laryngology,  and 
Diseases  of  the  Chest.  219  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  $1.25  net. 

THIRD  EDITION,  THOROUGHLY  REVISED  AND  ENLARGED. 
SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Lecturer  on  Clinical  and  Operative  Obstetrics,  University 
of  Pennsylvania.  Third  edition,  thoroughly  revised  and  enlarged.  Crown 
8vo.     Price,  Cloth,  interleaved  for  notes,  ^2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant ;  no  minor  rnatters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise." — New  York  Medical  Record. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  •' An  American  Text-Book 
of  Surgery."  By  N.  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surgery  in  Rusl 
Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.     Price,  ;^2.00. 

This  work  by  so  eminent  an  author,  himself  one  of  the  contributors  to 
•'An  American  TextBuok  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  wlio  has  adopted  that  work  as  his  text-book.  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  of  or  supplement  to  the  larger  work. 

"  The  autlior  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehen- 
sive, and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full 
references  are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology." — Britith 
Medical  Journal,  London. 


38  PV.   B.   SAUNDERS' 


THE  CARE  OF  THE  BABY.  By  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  404  pages,  with 
67  illustrations  in  the  text,  and  5  plates.      lamo.     Price,  ^1.50. 

SECOND  EDITION,  REVISED. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and 
practitioners  whose  opportunities  for  observing  children  have  been  limited. 

"  The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a  mas- 
ter hand.  It  can  be  read  with  benefit  not  only  by  mothers,  but  by  medical  students  and  by 
any  practitioners  who  have  not  had  large  opportunities  for  observing  children." — American 
Journal  of  Obstetrics. 

THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  m  the  ward  or  the  sick-room.  By  Honnor 
Morten,  author  of  "How  to  Become  a  Nurse,"  "Sketches  of  Hospital 
Life,"  etc.     i6mo,  140  pages.     Price,  Cloth,  $1.00. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up 
larger  and  fuller  works  on  the  subject. 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  Jerome  B.  Thomas, 
M.  D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital;  Assistant  Bacteriologist,  Brooklyn  Health  Department. 
Price,  Cloth,  ;^i.50    (Send  for  specimen  List.) 

One  hundred  and  sixty  detachable  (perforated)  diet  lists  for  Albuminuria, 
Ansemia  and  Debility,  Constipation,  Diabetes,  Diarrhoea,  Dyspepsia,  Fevers, 
Gout  or  Uric-Acid  Diathesis,  Obesity,  and  Tuberculosis.  Also  forty  detachable 
sheets  of  Sick-Room  Dietary,  containing  full  instructions  for  preparation  of 
easily-digested  foods  necessary  for  invalids.  Each  list  is  numbered  only,  the 
disease  for  which  it  is  to  be  used  in  no  case  being  mentioned,  an  index  key 
being  reserved  for  the  physician's  private  use. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND 
IN  DISEASE.  By  Louis  Starr,  M.  D.,  Editor  of  "An  American 
Text-Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size), 
perforated  and  neatly  bound  in  flexible  morocco.     Price,  ^1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant 
life;  each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food, 
the 'latter  directions  being  left  for  the  physician.  After  the  seventh  month, 
modifications  being  less  necessary,  the  diet  lists  are  printed  in  full.  Formula 
foi   tne  preparation  of  diluents  and  foods  are  appended. 


CATALOGUE   OF  MEDICAL    WORKS.  39 

HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  Jokn  M. 
Keating,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Psediatric  Society;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  211  pages,  with  two  large  half-tone  illustrations,  and  a  plate  prepared 
by  Dr.  McClellan  from  special  dissections;  also,  numerous  cuts  to  elucidate 
the  text.     Third  edition.      Price,  Cloth,  ^2.00  net. 

"  This  is  by  far  the  most  useful  book  v/hich  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  th-s  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — The  Medical  News,  Philadelphia. 

NURSING:  ITS  PRINCIPLES  AND  PRACTICE.  By  Isabel 
Adams  Hampton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital ;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  l2mo  volume  of  512 
pages,  illustrated.     Price,  Cloth,  ^2.00  net. 

SECOND   EDITION,  REVISED  AND  ENLARGED. 

This  original  work  on  the  important  subject  of  nursing  is  at  once  comprehensive 
and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suitable 
alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  desidera- 
tum with  those  entrusted  with  the  management  of  hospitals  and  liie  instruction  of 
nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  acquire  a  practical  working  knowledge  of  the  care  of  the  sick 
and  the  hygiene  of  the  sick-room. 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERA- 
TIONS. By  L.  Ch.  Boisi.iniere,  M.  D.,  late  Emeritus  Professor  of 
Obstetrics  in  the  St.  Louis  Medical  College.  381  pages,  handsomely  illus- 
trated.    Price,  ^2.00  net. 

"  For  the  use  of  the  practitioner  who,  when  away  from  home,  has  not  the 
opportunity  of  consulting  a  library  or  of  calling  a  friend  in  consultation.  He 
then,  being  thrown  upon  his  own  resources,  will  find  this  book  of  benefit  in 
guiding  and  assisting  him  in  emergencies." 

INFANT'S  WEIGHT  CHART,  Designed  by  J.  P.  Crozer  Griffith, 
M.  D.,  Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Peniv 
sylvania.    25  charts  in  each  pad.     Price  per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first 
two  years  of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight 
of  a  healthy  infant,  so  that  any  deviation  from  the  normal  can  readily  be  detected. 


Saunders' 
New  Series 
OF  Manuals 


for  Students 
and 
Practitioners* 


■'  I  'HAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading 
•*■  branches  of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the 
favor  with  which  the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been 
received  by  medical  students  and  practitioners  and  by  the  Medical  Press. 
These  manuals  are  not  merely  condensations  from  present  literature,  but 
are  ably  written  by  well-known  authors  and  practitioners,  most  of  them  being 
teachers  in  representative  American  colleges.  Each  volume  is  concisely  and 
authoritatively  written  and  exhaustive  in  detail,  without  being  encumbered 
with  the  introduction  of  "cases,"  which  so  largely  expand  the  ordinary  text- 
book. These  manuals  will  therefore  form  an  admirable  collection  of  advanced 
lectures,  useful  alike  to  the  medical  student  and  the  practitioner :  to  the  latter, 
loo  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value  ;  to  the  former  they  will 
afford  safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be 
superior  to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so 
much  information  in  such  a  concise  and  available  form.  A  liberal  expenditure 
has  enabled  the  publisher  to  render  the  mechanical  portion  of  the  work  worthy 
of  the  high  literary  standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page 
for  List). 


SAUNDERS'  NEW  SERIES  OF  MANUALS. 


VOLUMES  PUBLISHED. 


PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.  M.,  M.  D.,  Professor 
of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 
Island  College   Hospital,  etc.     Price,  5l-25  net. 

SURGERY,  General   and  Operative.     By   John   Chalmers  DaCosta, 

M.  D.,  Professor  of  Practice  of  Surgery  and  Clinical  Surgery,  Jefferson 
Medical  College,  Philadel(ihia.  Second  edition,  revised  and  greatly  en- 
larged. Octavo,  911  pages,  386  illustrations.  Cloth,  $4.00  net;  Hall'- 
Morocco,  ^5.00  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

By  E.  Q.  Thornton,  M.  D.,  Demonstrator  of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Price,  #1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc      Price,  ^1.50  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  $l.2S  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department 
of  the  New  York  University,  etc.     Price,  S2.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James 
Nevins  Hyde,  M.  D  ,  Professor  of  Skin  and  Venereal  Diseases,  and 
Frank  H.  Montgomery,  M.  D.,  Lecturer  on  Dermatology  and  Genito- 
urinary Diseases   in  Rush  Medical  College,  Chicago.     Price,  ^2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  of  the  New  York 
Infirmary,  etc.     Price,  ^2.50  net. 

OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Demon- 
strator of  Obstetrics,  University  of  Pennsylvania;  Chief  of  Gynecological 
Dispensary,  Pennsylvania  Hospital.     Price,  $2.50  net. 

DISEASES  OF  WOMEN.     By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant 

Surgeon  to  the  Middlesex  Hospital,  and  Surgeon  to  the  Chelsea  Hospital 
for  Women,  London ;  and  Arthur  E.  Giles,  M.  D.,  B.  Sc.  Lond.,  F.  R.  C.  S. 
Edin.,  Assistant  Surgeon  to  the  Chelsea  Hospital  for  Women,  London.  436 
pages,  handsomely  illustrated.     Price,  $2.50  net. 

IN    PREPARATION. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.  D.,  Clinical  Profes- 
sor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully  prepared  works 
on  various  subjects,  by  prominent  specialists. 

41 


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1.  ESSENTIALS  OF  PHYSIOLOGY.    4th  edition.    Illustrated.    Revised  and  enlarged 

By  H.  A.  Hare,  iM.  D.     (Price,  ^i.oo  net.) 

2.  ESSENTIALS  OF  SURGERY.    7th  edition,  with  a  chapter  on  Appendicitis.    90  illus- 

trations.    By  Edwahd  Mahtin,  M.  D.  (Price,  jiSt.oo  net  ) 

3.  ESSENTIALS  OF  ANATOMY.     6th  edition,  thoroughly  revised.     151  illustrations. 

By  Charles  B.  Nancrede,  M.  D.     (Price,  $1.00  net.) 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

5th  edition,  revised,  with  an  Appendix.     By  Lawrence  Wolff,  M.  D.     (^i. 00  net.) 

5.  ESSENTIALS  OF  OBSTETRICS.     4th  edition,  revised  and  enlarged.     75  illustra- 

tions.    By  W.  Easterly  Ashton,  M.  D. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY.     7th  thousand. 

46  illustrations.     By  C.  E.  Armand  Semple,  M.  D. 

7.  ESSENTIALS    OF    MATERIA      MEDICA,    THERAPEUTICS,    AND    PRE- 

SCRIPTION-WRITING.      5th  edition.      By  Henry  Morris,  M.  D. 

8.  g.  ESSENTIALS  OF  PRACTICE     OF    MEDICINE.      By  Henry  Morris,  M.  D. 

An  .'Vppeiidi.'c  on  Urine  Examin  ation.  Illustrated.  By  Lawrence  Wolff,  M.  D. 
3d  edition,  enlarged  by  some  300  Essential  Formulae,  selected  from  eminent  authori- 
ties, by  Wm.  M.  Powell,  INI.  D.     (Double  number,  price  ^2.00.) 

10.  ESSENTIALS  OF  GYN/ECOLOGY.     4th  edition,  revised.     With  62  illustrations. 

By  Edwin  B.  Cragin,  M.  D. 

11.  ESSENTIALS  OF  DISEASES  OF    THE  SKIN.  4th  edition,  revised  and  enlarged. 

71  letter-press  cuts  and  15  half-tone  illustrations.  By  Henry  W.  Stelwagon,  M.D. 
(Price,  jSi.oo  net.) 

12.  ESSENTIALS  OF  MINOR    SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.  2d  edition,  revised  and  enlarged.  78  illustrations.  By  Edward 
Martin,  M.  D. 

13.  ESSENTIALS  OF  LEGAL    MEDICINE,  TOXICOLOGY,  AND   HYGIENE. 

130  illustrations.     By  C.  E,    Armand  Semi-le,  M.  D. 

14.  ESSENTIALS  OF  DISEASES  OF   THE  EYE,  NOSE,  AND  THROAT.    124 

illustrations,  2d  edition,  revised.  By  Euwabd  Jackson,  M.  D.,  and  E.  Baldwin 
Gleason,  M.  D. 

15.  ESSENTIALS  OF   DISEASES  OF  CHILDREN.     2d  edition.     By  William  M. 

Powell,  M.D. 

16.  ESSENTIALS  OF  EXAMINATION    OF    URINE.      Colored   "  Vogel  Scale." 

and  numerous  illustrations.      By   Lawrence  Wolff,  M.  D.     (Price,  75  cents.) 

17.  ESSENTIALS  OF"  DIAGNOSIS.     2d  edition,  thoroughly  revised.     60  illustrations. 

By  S.  SiiLis-CoHiiN,  .M.  i^.,  and  A.  A.  Esmner,  M.  D.     (Price,  jfi.oonet.) 

18.  ESSENTIALS  OF   PRACTICE  OF  PHARMACY.     2d  edition,  revised.     By  L. 

E.  Sayre. 

20.  ESSENTIALS  OF   BACTERIOLOGY.      3d   edition.     82   illustrations.     By  M.  V. 

Ball,  M.  D. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY,   48  illustrations. 

3d  edition,  revised.     By  John  C.  Shaw,  M.  D. 

22.  ESSENTIALS  OF  MEDICAL  PHYSICS.     155  illustrations.     2d  edition,  revised. 

By  Fred  J.  Bkockway,  M.  I).     (Price,  Ji.oo  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.     65  illustrations.     By  David  D. 

Stewart,  M.  D.,  and  Edward  S.  Lawrance,  M.  D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE  EAR.     114  illustrations.    2d  edition,  re- 

vised and  enlarged.     By  E.  Baldwin  Gleason,  M.  D. 


Some  of  the  Books  in  Preparation  for 
Publication  during  1900. 


AMERICAN  Text=Book  of  Pa= 
thology. 

Edited  by  Ludvig  Hektoen,  M.D.,  Pro- 
fessor of  Pathology,  Rush  Medical  College, 
Chicago;  and  David  Riesman,  M.D.,  De- 
monstrator of  Pathological  Histology,  Uni- 
versity of  Pennsylvania. 

AMERICAN  Text=Book  of  Legal 
Medicine  and  Toxicology. 

Edited  by  Frederick  Peterson,  M.D., 
Chief  of  Clinic,  Nervous  Department,  College 
of  Physicians  and  Surgeons,  New  York  City ; 
and  Walter  S.  Haines,  M.D.,  Professor  of 
Chemistry,  Pharmacy,  and  Toxicology,  Rush 
Medical  College,  Chicago. 

BECK— Fractures. 

By  Carl  Beck,  M.D.,  Professor  of  Surgery 
in  the  N.  Y.  School  of  Clinical  Medicine. 

BOHM,  DAVIDOFF,  and  HU= 
BER-A  Text=Bookof  Human 
Histology. 

Including  Microscopic  Technic.  By 
Dr.  a.  a.  Bohm  and  Dr.  M.  von  Davidoff, 
of  the  Anatomical  Institute  of  Munich,  and 
G.  C.  HuBER,  M.D.,  Junior  Professor  of  Anat- 
omy and  Histology  ."University  of  Michigan, 
Ann  Arbor. 

EICHHORST— A  Text=Book  of 
the  Practice  of  Medicine. 

By  Dr.  Herman  Eichhorst,  Professor  of 
Special  Pathol  igy  and  Therapeutics  and  Di- 
rector of  the  Medical  Clinic,  University  of 
Zurich.  Translated  and  edited  by  Augustus 
A.  Eshner,  M  D  ,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic. 

FRIEDRICH  —  Rhinology,  La= 
ryngology,  and  Otology  in 
their  Relations  to  General 
Medicine. 

By  Dr.  E.  P.  Friedrich,  of  the  Univer- 
sity of  Leipsig. 

LEVY  AND  KLEMPERER  — 
The  Elements  of  Clinical  Bac° 
teriology. 

By  Dr.  Ernst  Levy,  Professor  in  the 
University  of  Stra.ssburg,  and  Dr.  Felix 
Klemperer,  Privat-Docent  in  the  Univer- 
sity of  Strassburg.  Translated  and  edited 
by  Augustus  A.  Eshner,  M.D.,  Professor 
of  Clinical  Medicine  in  the  Philadelphia  Poly- 
clinic.   Just  Ready.     Cloth,  J2. 50  net. 


McFARLAND— A  Text=Book  of 
Pathology. 

By  Joseph  McFarland,  M.D.,  Professor 
of  Pathology  and  Bacteriology,  Mcdico-Chi- 
rurgical  College,  Philadelphia. 

OGDEN  —  Clinical  Examination 
of  the  Urine. 

By  J.  Bergen  Ogden,  M.D.,  Assistant  in 
Chemistry,  Harvard  Medical  School. 

PYLE— A  Manual  of  Personal 
Hygiene. 

Edited  by  Walter  L.  Pyle,  M.D.,  Assis- 
tantSurgeon  to  Wills'  Eye  Hospital,  Philada. 

SCU ODER— The  Treatment  of 
Fractures. 

By  Charles  L.  Scudder,  M.D.,  Assistant 
in  Clinical  and  Operative  Surgery,  Harvard 
University. 

SENN— Practical  Surgery. 

By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D., 
Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery,  Rush  Medical  College,  Chi- 
cago. Octavo  volume  of  about  800  pages, 
profusely  illustrated. 

The  Pathology  and  Treatment 
of  Tumors. 

By  Nicholas  Senn,  M.D.,  Ph.D., LL.D., 

Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery,  Rush  Medical  College,  Chi- 
cago. A  New  and  Thoroughly  Revised  Edi- 
tion in  preparation. 

STENGEL  AND  WHITE  — The 
Blood  in  its  Clinical  and  Patho=' 
logical  Relations. 

By  Alfred  Stengel,  M.D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsyl- 
vania; and  C.  Y.  White,  M.D.,  Instruc- 
tor in  Clinical  Medicine,  University  of  Penn- 
sylvania. 

STEVENS— The  Physical  Diag= 
nosis  of  Diseases  of  the  Chest. 

By  A.  A.  Stevens,  A.M.,  M.D.,  Lecturer 
on  Terminology,  and  Instructor  in  Physical 
Diagnosis,  University  of  Pennsylvania. 

STONEY  —  Surgical  Technique 
for  Nurses. 

By  Emmy  A.  M.  Stoney,  late  Superin- 
tendent of  the  Training  Schools  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass. 


GRIFTITH 
ON  THE 
BABY 


THE  CARE  OF  THE  BABY.    By 

J.  P.  Crozer  Griffith,  M.D.,  Clinical 
Professor  of  Diseases  of 
Cfiildren,  University  of 
Pennsylvania ;  Physi- 
cian to  the   Children's 

Hospital,  Philadelphia,  etc.     Octavo. 

404  pages.     Illustrated.     Cloth,  $1.50. 

SECOND  EDITION,  REVISED. 

The  author  has  endeavored  to  furnish  a  reliable 
guide  for  mothers  anxious  to  inform  themselves 
with  regard  to  the  best  way  of  caring  for  their 


"The  best  book  for  the  use  of  the  young 
mother  with  which  we  are  acquainted.  There 
are  very  few  general  practitioners  who  could  not 
read  the  work  through  with  advantage." 

— Archives  of  Pediatrics. 


children  in  sickness  and  in  health.  He  has 
made  Iiis  statements  plain  and  easily  understood, 
in  the  hope  that  the  volume  may  be  of  service 


"  The  whole  book  is  characterized  by  rare 
good  sense,  and  is  evidently  written  by  a  master 
hand.  It  can  be  read  with  benefit  not  only  by 
mothers  but  by  medical  students  and  by  any 
practitioners  who  have  not  had  large  opportuni- 
ties for  observing  children." — American  Journal 
of  Obstetrics. 


not  only  to  mot'  .ers  and  nurses  but  also  to  med- 
ical students  and  to  practitioners  whose  oppor- 
tunities for  observing  cliildren  luve  been  limited. 


For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


Atlas  of  General  Surgery. 


/tiias  ui  f  syciiiairy. 

Atlas  of  Diseases  of  the  Ear. 


NERVOUS  AND  MENTAL  DIS- 
EASES. By  Archibald  Church,  M.D., 
Professor  of 
Clinical  Neu- 
rologfy,  Mental 
Diseases,  and 
Medical  Juris- 


CHURCH  AND 
PETERSON'S 
NERVOUS  AND 
MENTAL  DISEASES 


prudence.  Northwestern  University ; 
and  Frederick  Peterson,  M.D.,  Chief  of 
Clinic,  Nervous  Department,  College 
of  Physicians  and  Surgfeons,  New  York. 
Handsome  octavo,  843  pages,  with  over 
300  illustrations.  Cloth,  $5.00  net; 
Half  Morocco,  $6.00  net. 

SECOND   EDITION. 


This  book  is  intended  to  furnish  sludcnts  and 
practitioners  with  a  practical,  working  knowl- 
edge of  nervous  and  mencal  diseases.  Written 
by  men  of  wide  experience  and  authority,  it 
■will  present  the  many  recent  additions  to  the 
subject.  The  book  is  not  filled  w^ith  an  ex- 
tended dissertation  on  anatomy  and  pathology, 
but,  treating  these  points  in  connection  with 
special  conditions,  it  lays  particular  stress  on 
methods  of  examination,  diagnosis,  and  treat- 
ment. In  this  respect  the  work  is  unusually 
complete  and  valuable,  laying  dow^n  the  defi- 
nite courses  of  procedure  which  the  authors 
have  found  the  most  generally  satisfactory. 

For  sale  by  all  Booksellers,  or  sent  post-paid  on 
receipt  of  price. 

W.  B.  SAUNDERS,  Publisher, 

925  Walnut  St.,  Philadelphia. 


VOLUMES  NOW  READY. 


J 


"^ 


^C^ 


Atlas  of  Internal 

Dr.   Chr.  Jakob 
EsHNER,  M.D.,  Prll 
delphia  Polyclinic ; 
Hospital.     68  colo 

Atlas  of   Legal  M< 

Vienna.     Edited  t 
Professor  of  Menta 
York;  Chief  of  CI 
and  Surgeons,  I' 
plates,  and  193  1 

Atlas  of  Disease 

of  Munich.  Ec 
turer  on  Laryn^ 
Pennsylvania  ;  I 
ment,  Hospital  c 
figures  on  44  plat 

Atlas  of  Operati 

Vienna.  Edite<| 
Professor  of  Sur, 
Surgeon  to  the  P 
and  217  illustrai 

Atlas  of  Syphili 

Dr.  Franz  Mi 
Bangs,  M.D.,  1 
Diseases,  New  "V 
pital.     With  71 

A.   SCHMITSON 

Atlas  of  Extern 

of  Zurich.  Ec 
sor  of  Ophthal 
phia.  With  7 
113.00  net. 

Atlas  of  Skin  r><s«.«owo.     ^j  ^-.- 

Vienna.  Edited  by  Henry  W.  Stelwagon,  M.  D.,  Clinical 
Professor  of  Dermatology,  Jefferson  Medical  College,  Phila- 
delphia. With  63  colored  plates  and  39  beautiful  half-tone 
illustrations.     Cloth,  $3.50  net. 


S^ 


IN  PREPARATION. 


Atlas  of  Pathological  Histology. 
Atlas  of  Orthopedic  Surgery. 
Atlas  of  General  Surgery. 


Atlas  of  Operative  Gynecology. 

Atlas  of  Psychiatry. 

Atlas  of  Diseases  of  the  Ear. 


